A Fee for Service Plan with a Preferred Provider Organization Administered by the Alliance Health Benefit Plan
For changes benefits in
see pages Sponsored by The National Alliance of Postal and Federal Employees 4 5
Who may enroll in this Plan All eligible civilian employees and annuitants who become members or associ ate members of the National Alliance of Postal and Federal Employees NAPFE
To become a member or associate member At installations and subdivisions where there is a NAPFE local you may join as a regular or associate member If there is no local or you are an annuitant you will automati
cally become an associate member of the NAPFE
Membership dues 5.00 per month Members will have the option of paying dues on an annual or semi annu al basis Dues paid on an annual basis on or before March first of the plan year will receive a 10 discount
Enrollment code for this Plan
1R1 Self only
1R2 Self and family
Visit the Non OPM Postal website Premium at http www opm gov insure Postal Premium Biweekly
Biweekly Monthly and Category A Category B
our website at http www ahbp com Type of Gov t Your Gov t Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share
Self only YK1 64.43 36.89 139.60 79.93 80.54 20.78 000.00 000.00
Self and family YK2 139.60 75.19 302.47 162.91 174.50 40.29 000.00 000.00
Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
ETIREMENT AND INSURANCE 1
Alliance Health Benefit Plan 2000
Table of Contents
Page
Plain language 3
How to use this brochure 3
Section 1 Fee For Service Plans 4
Section 2 How we change for 2000 4 5
Section 3 How to get benefits 6 10
Section 4 What if we deny your claim or request for pre authorization 10 12
Section 5 Benefits 12 28
Section 6 How to file a claim 30 31
Section 7 General exclusions Things we don t cover 31 32
Section 8 Limitations Rules that affect your benefits 32 36
Section 9 Fee for Service facts 36 40
Section 10 FEHB facts 40 43
Department of Defense FEHB Demonstration Project 43 44
Inspector General Advisory Stop Healthcare Fraud 44
Summary of Benefits 45
Premiums back cover
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Alliance Health Benefit Plan 2000
Introduction National Alliance of Postal and Federal Employees 1628 11th Street NW Washington D C 20001
This brochure describes the benefits you can receive from Alliance Health Benefit Plan under its contract CS1164 with the Offi e of
Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This plan s medical and pre
scription drug benefits are administered by First Health with Merck Medco as the pharmacy mail order provider This plan s dental ben
efits are administered by Metlife
This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits
described in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these ben
efits Nothing anyone says can modify or otherwise affect the benefits limitations and exclusions of this brochure
Because OPM negotiates benefits and premiums annually they change each year This brochure describes the only benefits available
to you under this plan in 2000 Benefit changes are effective January 1 2000 and are shown on pages 4 5 You do not have a right to
benefits that were available before January 1 2000 unless those benefits are also contained in this brochure Premiums are listed at the
end of this brochure
Plain Language The President and Vice President are making the Government s communication more responsive accessible and understandable to the
public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have worked
cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical
terms you and other personal pronouns active voice and short sentences
We refer to Alliance Health Benefit Plan as this Plan throughout this brochure even though in other legal documents you will see a
plan referred to as a carrier
Sections one two four and ten are now in plain language as well as portions of sections three and eight We will rewrite the remain
ing sections of this brochure including the benefits section for year 2001 Please note that the format and organization of this brochure
have changed as well
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
How to use this brochure This brochure has ten sections Each section has important information you should read If you want to compare this Plan s benefits
with other benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Fee for Service Plan FFS This Plan is a FFS Plan Turn to this section for a brief description of Fee for Service plans and how
they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get benefits and how we operate
4 What if we deny your claim or request for pre authorization This section tells you what to do if you disagree with our decision
not to pay your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find infor
mation about non FEHB benefits
6 How to file a claim Look here to find specific information on how to file claims with us
7 General exclusions Things we don t cover Look here to see benefits that we will not provide
8 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
9 Fee for Service facts This section contains information about pre certification protection against catastrophic expenses and a
definition section
10 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
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Alliance Health Benefit Plan 2000
Section 1 Fee for Service Plans
Fee for Service plans reimburse you or your provider for covered services They do not typically provide or arrange for health care
Fee for Service plans let you choose your own physicians hospitals and other health care providers
The FFS plan reimburses you for your health care expenses usually on a percentage basis These percentages as well as deductibles meth
ods for applying deductibles to families and the percentage of coinsurance you must pay vary by plan The type and extent of covered ser
vices varies by plan There is a detailed explanation of the benefits we offer in this brochure you should read it carefully
This FFS plan offers a preferred provider organization PPO arrangement This arrangement with health care providers gives you enhanced
benefits or limits your out of pocket expenses
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary Changes care office visits
This year you have a right to more information about this Plan care management our networks
facilities and providers
If you have a chronic or disabling condition or are in the second or third trimester of pregnancy
and your provider is leaving our PPO network at our request without cause we will notify you You
may continue to receive our PPO level benefits for your specialist s services for up to 90 days after
you receive notice We will provide regular non PPO benefits for the specialist s services after the
90 day period expires
You may receive and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a
record that is not accurate not relevant or incomplete If the physician does not amend your record
you may add a brief statement to it If they do not provide you your records call us and we will
assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer
Changes to Your share of the non postal premium will decrease by 10.9 for Self Only or 12.5 for Self and This Plan Family
PPO Network First Health administers this Plan on behalf of the carrier and is referred to as carri
er in this brochure The Plan has entered into an arrangement with First Health to use the First
Health Network a Preferred Provider Organization PPO This PPO operates in 49 states plus
Puerto Rico and the District of Columbia
Surgical Benefits Assistant Surgeon inpatient outpatient
PPO benefit After the 100 PPO calendar year deductible has been met the Plan pays 90 of the
assistant surgeon expenses not to exceed 20 of the reasonable and customary charge of the sur
gical procedure
Non PPO benefit After the 300 non PPO calendar year deductible has been met the Plan pays
70 of the assistant surgeon expenses not to exceed 20 of the reasonable and customary charge
of the surgical procedure
Organ tissue transplant and donor expenses In a Managed Transplant Network facility transplants
are covered at 90 with travel and donor organ procurement covered to a 10,000 maximum
When a facility in the First Health Network is used for a transplant the Plan pays 80 for the trans
plant with a 150,000 maximum for a liver transplant and 100,000 maximum for other transplants
The travel and lodging allowance is not covered
When a non PPO facility is used the Plan pays 70 for the transplant with a 150,000 maximum
for a liver transplant and 100,000 maximum for other transplants Travel and lodging allowance is
not covered
Mental conditions Inpatient care After a 500 deductible per person per confinement the Plan
will pay 80 of the PPO contracted rate for a PPO facility or reasonable and customary charges of
a non PPO facility Benefits for inpatient mental conditions will be limited to 45 days per person
per calendar year
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Alliance Health Benefit Plan 2000
Section 2 How we change for 2000 continued
Mental conditions Inpatient visits and Outpatient care PPO benefit After the 100 PPO calendar
year deductible has been met doctors visits inpatient and outpatient for treatment of mental con
ditions are paid at 50 of the PPO contracted rate
Non PPO benefit After the 300 non PPO calendar year deductible has been met doctors visits
inpatient and outpatient for the treatment of mental conditions are paid at 50 of reasonable and
customary charges
The maximum number of doctors visits inpatient and outpatient is limited to 45 visits PPO and
non PPO combined per person per calendar year
Substance abuse Inpatient care PPO benefit After the 100 PPO calendar year deductible has been
met the Plan pays 100 of the PPO contracted rate for substance abuse treatment up to 4,000
annually
Non PPO benefit After the 300 non PPO calendar year deductible has been met the Plan pays
80 of reasonable and customary charges for substance abuse treatment up to 4,000 annually
Lifetime maximum is 60 inpatient days per person
Substance abuse Outpatient care PPO benefit After the 100 calendar year deductible has been
met outpatient doctors visits for the treatment of substance abuse are paid at 75 of the PPO con
tracted rate
Non PPO benefit After the 300 non PPO calendar year deductible has been met outpatient doc
tors visits for the treatment of substance abuse are paid at 50 of reasonable and customary
charges
The maximum benefit for outpatient doctors visits for treatment of substance abuse is limited to
4,000 maximum per person per calendar year PPO and non PPO combined
Cardiac Rehabilitation Program PPO benefit After the 100 PPO calendar year deductible has
been met the Plan pays 70 of the PPO contracted rate
Non PPO benefit After the 300 non PPO calendar year deductible has been met the Plan pays
50 of reasonable and customary charges There is no limitation on the number of visits covered
Smoking cessation benefit PPO benefit After the 100 PPO calendar year deductible has been
met smoking cessation benefits are limited to 100 for one smoking cessation program per mem
ber per lifetime
Non PPO benefit After satisfaction of the 300 non PPO calendar year deductible has been met
smoking cessation benefits are limited to 100 for one smoking cessation program per member per
lifetime
Medical Emergency After the 25 copay for an emergency room visit the Plan pays 100 of the
PPO contracted rate or the reasonable and customary charges for the initial treatment in the emer
gency room of a hospital as a result of a medical emergency as defined on page 24 Other med
ical benefits are available for covered services and supplies that are provided in a doctor s office or
are not a result of a medical emergency
Chiropractor PPO benefit After the 100 PPO calendar year deductible has been met the plan
pays 90 of the PPO contracted rate
Non PPO benefit After the 300 non PPO calendar year deductible has been met the Plan pays
70 of reasonable and customary charges
Benefits are limited to a maximum of 225 per person per calendar year PPO and non PPO com
bined for outpatient services
Prescription Drug Benefit When Medicare is primary The waiver of the deductible when
Medicare is primary is eliminated Prescription Drug Benefit By mail After satisfying your com
bined annual 200 per person prescription drug deductible the Plan pays 80 of the charges per gener
ic or brand name medication
Pre admission testing will be paid as Other Hospital Charges or as Other Medical Benefits
depending on how the testing is billed
The dental benefit provider for this plan is The Metlife Dental Program
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Alliance Health Benefit Plan 2000
Section 3 How to get benefits
How do I keep my health care
expenses down
You can help FEHB plans are expected to manage their costs prudently All FEHB plans have cost containment measures in place All fee for service plans include two specific provisions in their benefit pack
ages precertification of all inpatient admissions and the flexible benefits option Some include
managed care options such as PPOs to help contain costs
As a result of your cooperative efforts the FEHB Program has been able to control premium costs
Please keep up the good work and continue to help keep costs down
Precertification Precertification evaluates the medical necessity of proposed admissions and the number of days required to treat your condition You are responsible for ensuring that the precertification require
ment is met You or your doctor must contact First Health before being admitted to a hospital If
that doesn t happen your Plan will reduce benefits by 500 Be a responsible consumer Be aware
of your Plan s cost containment provisions You can avoid penalties and help keep premiums under
control by following the procedures specified on page 12 of this brochure
Flexible benefits Under the flexible benefits option the Carrier has the authority to determine the most effective way option to provide services The Carrier may identify medically appropriate alternatives to traditional care
and coordinate the provision of Plan benefits as a less costly alternative benefit Alternative bene
fits are subject to ongoing review The Carrier may decide to resume regular contract benefits at its
sole discretion Approval of an alternative benefit is not a guarantee of any future alternative ben
efits The decision to offer an alternative benefit is solely the Carrier s and may be withdrawn at
any time It is not subject to OPM review under the disputed claims process
PPO This Plan offers most of its members the opportunity to reduce out of pocket expenses by choos ing providers who participate in the Plan s preferred provider organization PPO Consider the
PPO cost savings when you review Plan benefits and check with the Carrier to see whether PPO
providers are available in your area
How much do I You must share the cost of some services These cost sharing measures include deductibles coin pay for services surance and copayments These and other measures are described in more detail below
Deductibles A deductible is the amount of expense an individual must incur for covered services and supplies before the Plan starts paying benefits for the expense involved A deductible is not reimbursable by
the Plan When a benefit is subject to a deductible only expenses allowable under that benefit count
toward the deductible
Calendar year The calendar year deductible is the amount of expenses an individual must incur for covered ser vices and supplies each calendar year before the Plan pays certain benefits The deductible for PPO
benefits is 100 per person the deductible for non PPO benefits is 300 Any expenses incurred
through PPO or non PPO benefits are applied toward both deductibles
Other There is a 150 per admission deductible for PPO benefits and a 250 per admission deductible for non PPO benefits which apply to inpatient hospital benefits pages 12 13 and a separate 500
deductible per person per confinement which applies to inpatient hospital charges for the treatment
of mental conditions page 20 There is a combined 200 annual deductible applicable to mail
order and or retail prescription drug programs
Carryover If you changed to this Plan during open season from a plan with a deductible and the effective date of the change was after January 1 any expenses that would have applied to that plan s deductible
in the prior year will be covered by your old plan if they are for care you got in January before the
effective date of your coverage in this Plan If you have already met the deductible in full your old
plan will reimburse these covered expenses If you have not met it in full your old plan will first
apply your covered expenses to satisfy the rest of the deductible and then reimburse you for any
additional covered expenses The old plan will pay these covered expenses according to this year s
benefits benefit changes are effective January 1
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Alliance Health Benefit Plan 2000
Section 3 How to get benefits continued
Family limit There is a separate calendar year deductible of 100 per person for PPO benefits and a 300 per person for non PPO benefits Under a family enrollment the deductible is considered satisfied and
benefits are payable for all family members after three members have met their calendar year
deductible If the PPO deductibles are satisfied then further deductibles are waived for PPO
charges during that calendar year If the non PPO deductibles are satisfied then further PPO and
non PPO deductibles are waived
Coinsurance Coinsurance is the stated percentage of covered charges you must pay after you have met any applicable deductible You are required to pay the following coinsurance on benefits under this Plan
10 for PPO inpatient hospital room board and other hospital charges
30 for non PPO inpatient hospital room board and other hospital charges
10 for PPO inpatient and outpatient surgical benefits maternity benefits and other medical
benefits
30 for non PPO inpatient and outpatient surgical benefits maternity benefits and other med
ical benefits
20 for inpatient treatment of mental conditions
50 for doctors visits inpatient and outpatient for mental conditions
20 for non PPO inpatient treatment of substance abuse
25 for PPO outpatient treatment of substance abuse
50 for non PPO outpatient treatment of substance abuse
20 for skilled nursing facility
After you meet any deductible the coinsurance is the minimum amount you will have to pay For
instance when a Plan pays 70 of reasonable and customary charges for a covered service you
are responsible for 30 of the reasonable and customary charges i e the coinsurance In addition
you may be responsible for any excess charge over the Plan s reasonable and customary allowance
For example if the provider ordinarily charges 100 for a service but the Plan s reasonable and cus
tomary allowance is 95 the Plan will pay 70 of the allowance 66.50 You must pay the 30
coinsurance 28.50 plus the difference between the actual charge and the reasonable and cus
tomary allowance 5 for a total member responsibility of 33.50 Remember if you use networproviders
your share of covered charges after meeting any deductible is limited to the stated coin
surance amount
Copayment A copayment is the stated amount the Plan may require you to pay for a covered service such as a 10 per office visit charge at a PPO provider
If a provider waives If a provider routinely waives does not require you to pay your share of the charge for services your share rendered the Plan is not obligated to pay the full percentage of the amount of the provider s origi
nal charge it would have otherwise have paid A provider or supplier who routinely waives coin
surance copayments or deductibles is misstating the actual charge This practice may be in viola
tion of the law The Plan will base its percentage on the fee actually charged For example if the
provider ordinarily charges 100 for a service but routinely waives the 30 coinsurance the actual
charge is 70 The Plan will pay 49 70 of the actual charge of 70
Lifetime Benefits for inpatient substance abuse treatment are limited to 60 inpatient days per person per life maximums time
Smoking cessation benefits are limited to 100 for one smoking cessation program per member per
lifetime
Do I have to submit You usually do not have to submit claims to us if you use preferred providers If you file a claim claims please send us all of the documents for your claim as soon as possible You must submit claims by
December 31 of the year after the year you received the service Either OPM or we can extend this
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Alliance Health Benefit Plan 2000
Section 3 How to get benefits continued
deadline if you show that circumstances beyond your control prevented you from filing on time
Please see section 6 How to file a claim for specific information you need to know before you file
a claim with us
Who provides my In a Fee for Service Plan you may choose any covered facility or provider health care
Covered facilities
Birthing Center A free standing facility licensed or certified by the State in which it functions or Plan approved which offers comprehensive maternity care in a home like atmosphere
Hospice A facility which provides short periods of stay for a terminally ill person in a home like setting for either direct care or respite This facility may either be free standing or affiliated with a hospital It
must operate as an integral part of the hospice care program
Hospital An institution licensed by the State or conforming to the standards of and accredited by the Joint Commission on Accreditation of Health Care Organizations JCAHO providing inpatient diag
nostic and therapeutic facilities for surgical and medical diagnosis treatment and care of injured
and sick persons by or under the supervision of a staff of licensed doctors of medicine M D or
licensed doctors of osteopathy D O The hospital must provide continuous 24 hour a day profes
sional registered nursing R N services and may not be an Extended Care Facility other than an
approved ECF nursing home a place for rest an institution for exceptional children the aged
drug addicts or alcoholics or a custodial or domiciliary institution having the primary purpose of
furnishing food shelter training or non medical personal services This definition includes college
infirmaries and Veterans Administration Hospitals
Skilled nursing An institution or that part of an institution which provides skilled nursing care 24 hours a day facility
Covered providers For the purpose of this Plan covered providers include
1 a licensed doctor of medicine M D or a licensed doctor of osteopathy D O and a licensed
podiatrist practicing within the scope of the license
2 other covered providers include a Chiropractor Dentist Optometrist Clinical Psychologist
Clinical Social Worker Nurse Midwife Nurse Practitioner Clinical Specialist Nurse Anesthetist or
Nursing School Administered Clinic Charges of Christian Science nurses practitioners and
providers will be covered under this plan the same as other medical providers For the purpose of
this FEHB brochure the term doctor includes all of these providers when the services are per
formed within the scope of their license or certification
Coverage in Within States designated as medically under served areas any licensed medical practitioner will be medically treated as a covered provider for any covered services performed within the scope of that license
under served For 2000 the States designated as medically under served are Alabama Idaho Kentucky areas Louisiana Mississippi Missouri New Mexico North Dakota South Carolina South Dakota Utah
and Wyoming
PPO arrangements Benefits under this Plan are available from facilities such as hospitals and from providers such as pharmacies doctors and other health care personnel who provide covered services This Plan cov
ers two types of facilities and providers 1 those who participate in a preferred provider organi
zation PPO and 2 those who do not Who these health care providers are and how benefits are
paid for their services are explained below
PPO facilities and providers have agreed to provide services to Plan members at a lower cost than
you d usually pay a non PPO provider Although PPO s are not available in all locations or for all
services when you use these providers you can help contain health care costs and reduce what you
pay out of pocket The selection of PPO providers is solely the Plan s responsibility continued par
ticipation of any specific provider cannot be guaranteed While PPO providers agree with the
Carrier to provide covered services final decisions about health care are the sole responsibility of
the doctor and patient and are independent of the terms of the insurance contract
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Alliance Health Benefit Plan 2000
Section 3 How to get benefits continued
PPO benefits apply only when you use a PPO provider Provider networks may be more extensive in
some areas than others The availability of every specialty in all areas cannot be guaranteed If no
PPO provider is available or you do not use a PPO provider the standard non PPO benefits apply
When you use a PPO hospital keep in mind that the professionals who provide services to you in
the hospital such as radiologists anesthetists and pathologists may not all be preferred providers
If they are not they will be paid by this plan as non PPO providers
Non PPO facilities and providers do not have special agreements with the Carrier The Plan makes
its regular payments towards the bills and you are responsible for any balance
This Plan s The Plan has entered into an agreement with First Health to use The First Health Network a PPO Preferred Provider Organization PPO This is a group of doctors hospitals and other providers who
have contracted with First Health to provide medical services at reduced cost This PPO operates in
49 states plus Puerto Rico and the District of Columbia Each time you need medical care you have
the choice to use a health care provider who participates in the network or one who doesn t
When you use a PPO hospital your benefits increase from 70 after the 250 inpatient deductible
to 90 after the 150 inpatient deductible When you use a PPO doctor your surgery benefits
increase to 90 after a 100 deductible and your office visit benefits increase to paid in full after
a 10 copayment Non PPO benefits for both are 70 after a 300 deductible Precertification is
required as explained on page 12 for all inpatient hospitalizations It is your responsibility to com
plete this prior notification however your PPO doctor may initiate precertification and will file
your claims for you Note PPO benefits are not payable when the Alliance Health Benefit Plan is
not the primary payer
New enrollees living in a PPO area will receive a directory of PPO providers in their service area
Providers who belong to the network must meet specific criteria including location medical spe
cialty professional skill and proper credentials However inclusion in the network neither repre
sents a guarantee of professional performance nor constitutes medical advice The continued avail
ability of any one provider cannot be guaranteed by the Plan Call 1 800 225 4423 24 hours a day
7 days a week for information on how to nominate or request provider network participation or to
obtain a list of PPO providers in your area A list of PPO providers may also be obtained from First
Health s web site at http www firsthealth com MainMenu hcc polnum nap When you phone for
an appointment please remember to verify that the physician is still a PPO provider
What do I do if I m in First call our customer service department at 1 800 225 4423 If you are new to the FEHB the hospital when I join Program we will reimburse your covered expenses If you are currently in the FEHB Program and
this Plan are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
You exhaust the benefits available from your former plan or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
What if I have a serious Please contact us if you believe your condition is chronic or disabling If it is you may be able to con illness and my provider tinue seeing your provider for up to 90 days after you receive notice that we are terminating our con
leaves the Plan or this tract with the provider unless the termination is for cause If you are in the second or third trimester Plan leaves the Program of pregnancy you may continue to see your OB GYN until the end of your postpartum care
You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new plan will pay for or provide
your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB
Program If you are in your second or third trimester your new plan will pay for the OB GYN care
you receive from your current provider until the end of your postpartum care
If you continue seeing your specialist or OB GYN under these conditions your cost will be no
more than you would normally pay for services covered
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Alliance Health Benefit Plan 2000
Section 3 How to get benefits continued
How do I decide if a service is experimental
or investigational
Experimental or A drug device or biological product is experimental or investigational investigational
1 If the drug device or biological product cannot be lawfully marketed without approval of the
U S Food and Drug Administration FDA and approval for marketing has not been given at the
time the drug or device is furnished Approval means all forms of acceptance by the FDA
2 An FDA approved drug device or biological product for use other than its intended purposes
and labeled indications or medical treatment or procedure is experimental or investigational if 1
reliable evidence shows that it is the subject of ongoing phase I II or III clinical trials or under
study to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy as
compared with the standard means of treatment or diagnosis or 2 reliable evidence shows that the
consensus of opinion among experts regarding the drug device or biological product or medical
treatment or procedure is that further studies or clinical trials are necessary to determine its maxi
mum tolerated dose its toxicity its safety its efficacy or its efficacy as compared with the stan
dard means of treatment or diagnosis
3 Reliable evidence shall mean only published reports and articles in the authoritative medical and
scientific literature the written protocol or protocols used by the treating facility or the protocol s
of another facility studying substantially the same drug device or medical treatment or procedure
or the written informed consent used by the treating facility or by another facility studying substan
tially the same drug device or medical treatment or procedure
FDA approved drugs devices or biological products used for their intended purposes and labeled
indications and those that have received FDA approval subject to postmarketing approval clinical
trials and devices classified by the FDA as Category B Non experimental Investigational Devices
are not considered experimental or investigational
Determination of experimental investigational status may require review of appropriate govern
ment publications such as those of the National Institute of Health National Cancer Institute
Agency for Health Care Policy and Research Food and Drug Administration and National Library
of Medicine
Independent evaluation and opinion by Board Certified Physicians may be obtained for their exper
tise in subspecialty areas
Section 4 What if we deny your claim or request for pre authorization
What should I do Before you ask us to reconsider your claim you should first check with your provider or facility to before filing a be sure that the claim was filed correctly For instance did the provider use the correct procedure
disputed claim code for the services performed surgery laboratory test X ray office visit etc Have your provider indicate any complications of any surgical procedures performed Your provider should also
include copies of an operative or procedure report or other documentation that supports your claim
If we deny your request for pre authorization or won t pay your claim you may ask us to recon
sider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time
if you show that you were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Approve your request for pre authorization or
4 Ask for more information
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Alliance Health Benefit Plan 2000
Section 4 What if we deny your claim or request for pre authorization continued
If we ask your medical provider for more information we will send you a copy of our request We
must make a decision within 30 days after we receive the additional information If we do not
receive the requested information within 60 days we will make our decision based on the infor
mation we already have
When may I ask OPM to You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim
or request for service
What if I have a serious Call us at 1 800 321 0347 and we will expedite our review life threatening condition
and you haven t responded to my request for
pre authorization
What if you have denied If we expedite your review due to a serious medical condition and deny your request we will my request for care and inform OPM so that they can give your claim expedited treatment too Alternatively you can call
my condition is serious OPM s health benefits Contract Division II at 202 606 3818 between 8 a m and 5 p m Serious or life threatening or life threatening conditions are ones that may cause permanent loss of bodily functions or death
if they are not treated as soon as possible
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our limits initial denial or refusal You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request with
in 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days
In this case OPM must receive your request within 120 days of the date we asked you for addi
tional information
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following infor mation
1 A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to
which claim
Who can make the Those who have a legal right to file a disputed claim with OPM are request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled per
son s representative They must send a copy of the person s specific written consent with the
review request
Where should I mail my Send your request for review to Office of Personnel Management Office of Insurance Programs disputed claim to OPM Contracts Division II P O Box 436 Washington D C 20004
What if OPM upholds OPM s decision is final There are no other administrative appeals If OPM agrees with our deci the Plan s denial sion your only recourse is to sue
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Alliance Health Benefit Plan 2000
Section 4 What if we deny your claim or request for pre authorization continued
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may
recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services or drugs covered by us until you have completed the OPM review procedure described
above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you the Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the
review process becomes a permanent part of your disputed claims file and is subject to the provi
sions of the Freedom of Information Act and the Priva y Act OPM may disclose this information
to support the disputed claim decision If you file a lawsuit this information will become part of
the court record
Section 5 Benefits
Inpatient Hospital Benefits
What is covered The Plan pays for inpatient hospital services as shown below
Precertification You are required to call the First Health OnCall toll free number 1 800 225 4423 for all inpa tient admissions including any elective admission to a hospital The medical necessity of your hos
pital admission must be certified for you to receive full Plan benefits You must call the toll free
number when a maternity stay extends beyond 48 hours following a normal vaginal delivery or 96
hours following a Cesarean section delivery For mental health and substance abuse inpatient
admissions the medical necessity of your admission to a hospital or other covered facility must be
precertified for you to receive full Plan benefits You are required to call the toll free number with
in 48 hours 2 working days of any emergency admission even if you have been discharged
Otherwise the benefits payable will be reduced by 500 See pages 36 37 for details
Wai ve r This precertification does not apply to persons whose primary coverage is Medicare Part A or another health insurance policy or when the hospital admission is outside the United States or
Puerto Rico For information on when Medicare is primary see pages 32 34
Room and board Semiprivate room accommodations including general nursing care meals and special diets are covered If a private room is used only the hospital s average semiprivate room rate will be con
sidered a covered expense However if the patient s isolation is medically necessary to prevent con
tagion to others the full charge for a private room will be covered If a private room is chosen ben
efits will be determined based on the hospital s semiprivate room rate as determined by the Plan
If the hospital has private accommodations only the Plan will determine benefits based on the
semiprivate room charge of the hospital which the plan determines to be the most comparable hos
pital in the area
PPO benefit After a 150 deductible per admission the Plan pays 90 of room and board charges
Non PPO After a 250 deductible per admission the Plan pays 70 of room and board charges benefit
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
Other charges Other hospital charges include but are not limited to
Ancillary services such as electrocardiograms and electroencephalograms
Intravenous solutions and injections
Oxygen including use of equipment and administration
Use of operating recovery intensive care and ystoscopic rooms
Laboratory tests
Surgical dressings plaster casts and sterile tray service
Diagnostic X rays
Drugs and medicines
Blood or blood plasma if not donated or replaced and its administration
Radiation therapy and inhalation therapy
Renal dialysis
Pre admission testing
PPO The Plan pays 90 of other hospital charges benefit
Non PPO The Plan pays 70 of other hospital charges benefit
Limited benefits
Hospitalization for The Plan pays hospital benefits as shown on pages 12 13 for covered room and board and cov dental work ered hospital services for hospitalization in connection with dental procedures only when a non
dental physical impairment exists which makes hospitalization necessary to safeguard the health of
the patient
Related benefits
Professional Covered professional services of a doctor or any other covered practitioner even though billed by charges a hospital as part of hospital services are covered only under Other Medical Benefits page 21
Drugs medical supplies appliances medical equipment and any covered items billed by a hospi Take home
tal but to be used at home are covered only under Other Medical Benefits page 21 items
What is not A hospital admission or part of a hospital admission and inpatient doctor care that is not med covered ically necessary i e the medical services did not require the acute hospital inpatient overnight
setting but could have been provided in a doctor s office the outpatient department of a hos
pital or some other setting without adversely affecting the patient s condition or the quality of
medical care rendered
Confinement in nursing homes rest homes places for the aged convalescent homes residen
tial treatment facilities or any place that is not a hospital see definition on page 8
Custodial care as defined on page 39
Inpatient private duty nursing
Personal comfort services of a luxury nature such as radio telephone beauty and barber ser
vices ID tags baby beads footprints guest meals and newspapers
Admissions for cosmetic services
Admissions for rehabilitative services that are not covered by this Plan
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
Surgical Benefits
What is covered The Plan pays for the following services
Hospital inpatient
PPO After the 100 PPO calendar year deductible has been met the Plan pays 90 of the PPO con benefit tracted rate
Non PPO After the 300 non PPO calendar year deductible has been met the Plan pays 70 of reasonable benefit and customary charges
Outpatient The Plan pays reasonable and customary charges to the extent shown below for outpatient covered services and supplies provided by a doctor in relation to and on the same day as the covered out
patient surgery Covered services and supplies rendered prior to or after the date of surgery are eli
gible for Other Medical Benefits
Surgery by a doctor surgeon or licensed podiatrist
Voluntary sterilization
Charges for normal postoperative care by the doctor who performs surgery are considered to be
part of the surgical charge
PPO benefit After the 100 PPO calendar year deductible has been met the Plan pays 90 of the PPO con tracted rate
Non PPO benefit After the 300 non PPO calendar year deductible has been met the Plan pays 70 of reasonable and customary charges
Precertification You are required to call the First Health OnCall toll free number 1 800 225 4423 before receiv ing right sided heart catheterization
Waiver Precertification is not required for any individual who has Medicare Part A and B as primary cov erage or for treatment outside the United States and Puerto Rico For information on when
Medicare is primary see pages 37
Same day surgery The Plan provides benefits for hospital billed services and supplies when provided by and in a hos pital outpatient department or emergency room in connection with in and out patient surgery where
minor surgery is performed and the patient goes home the same day the surgery is performed
PPO benefit After the 100 PPO calendar year deductible has been met the Plan pays 90 of the PPO con tracted rate
Non PPO benefit After the 300 non PPO calendar year deductible has been met the Plan pays 70 of reasonable and customary charges
Multiple surgical When multiple or bilateral surgical procedures that add time or complexity to patient care are per procedures formed during the same operative session the Plan pays as follows
If more than one procedure is performed during one operation through the same incision or nat
ural body orifice or in the same operative field payment will be made as follows 100 for the
primary procedure 50 for the second procedure and 25 for procedures thereafter
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
Incidental If primary and incidental procedures are performed the Plan pays the full allowance for the pri procedures mary procedure only There are no additional benefits for the incidental procedures Incidental
and subset procedures are considered as part of the primary surgery
Assistant surgeon PPO After the 100 PPO calendar year deductible has been met the Plan pays 90 inpatient outpatient benefit of the assistant surgeon expenses not to exceed 20 of the reasonable and cus
tomary charge of the surgical procedure
Non PPO After the 300 non PPO calendar year deductible has been met the Plan pays benefit 70 of the assistant surgeon expenses not to exceed 20 of the reasonable
and customary charge of the surgical procedure
Second opinion See Other Medical Benefits page 21 voluntary
Ambulatory surgical The Plan pays for covered hospital services and supplies received for covered surgical procedures facility surgicenter in an Ambulatory Surgical Facility or SurgiCenter as follows
PPO After the 100 PPO calendar year deductible has been met the Plan pays 90 benefit of the PPO contracted rate
Non PPO After the 300 non PPO calendar year deductible has been met the Plan pays benefit 70 of reasonable and customary charges
Anesthesia The Plan pays reasonable and customary charges for the administration of anesthesia as follows
PPO After the 100 PPO calendar year deductible has been met the Plan pays 90 benefit of the PPO contracted rate
Non PPO After the 300 non PPO calendar year deductible has been met the Plan pays benefit 70 of reasonable and customary charges
Organ tissue All reasonable and customary charges incurred for a covered surgical transplant whether incurred transplants and by the recipient or donor and expenses for covered organ transplants will be considered expenses
donor expenses of the recipient and will be covered the same as for any other illness or injury When a First Health National Transplant Program facility is used after the 100 PPO calendar year deductible has been
met the Plan pays 90 of the transplant program contracted rate for a covered surgical transplant
When a First Health National Transplant Program facility is not used but a First Health Networfacility
is used after the 100 PPO calendar year deductible has been met the Plan pays 80 of the
PPO negotiated rate When a non PPO facility is used after the 300 calendar year deductible has
been met the Plan pays 70 of reasonable and customary charges
This benefit applies only if the recipient is covered by the Plan and to the extent that the donor s
expenses are not covered Recipient means an insured person who undergoes an operation to
receive an organ transplant donor means a person who undergoes an operation for the purpose of
donating an organ for transplant surgery
Covered When all of the provisions of the First Health National Transplant Program are satisfied the Plan transplants will provide benefits for the procedures and services listed in this section
Cornea heart kidney heart lung liver pancreas when condition is not treatable by use of insulin
therapy
Single or double lung transplants for the following end stage pulmonary diseases 1 Primary fibro
sis 2 Primary pulmonary hypertension and 3 Emphysema Double lung transplant for ystic
fibrosis
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
Bone marrow and stem cell support as follows Allogeneic bone marrow transplants for 1 Acute
leukemia 2 Advanced Hodgkin s lymphoma 3 Advanced non Hodgkin s lymphoma 4
Advanced neuroblastoma limited to children over age one 5 Aplastic anemia 6 Chronic myel
ogenous leukemia 7 Infantile malignant osteopetrosis 8 Severe combined immunodeficiency 9
Thalassemia major and 10 Wiskott Aldrich syndrome
Autologous bone marrow transplants autologous stem cell support and autologous peripheral
stem cell support for 1 Acute lymphocytic or non lymphocytic leukemia 2 Advanced Hodgkin s
lymphoma 3 Advanced non Hodgkin s lymphoma 4 Advanced neuroblastoma and 5 Testicular
Mediastinal Retroperitoneal and Ovarian germ cell tumors Breast cancer Multiple myeloma and
Epithelial ovarian cancer
First Health National Transplant Program
Covered Transplant Pre transplant evaluation Services
Organ procurement
Transplant procedures and associated hospitalization
Transplant related follow up care provided by the designated transplant hospital for up to 1 year
Pharmacy costs provided by the the First Health National Transplant Program for immunosup
pressant and other transplant related medications while hospitalized
Donor expenses if not covered under any other plan
Transplant related services provided by the First Health National Transplant Program facility that are
associated with the transplant events listed above including laboratory and other diagnostic services
Physician services related to the transplant events listed above
Travel and lodging benefit expenses for the patient donor and one other individual if the patient donor lives at least 100 miles from the designated facility If the patient is a minor the Plan
will consider expenses for two individuals to accompany the patient Benefits also include travel
and lodging to a designated transplant facility for the pre transplant evaluation Travel and lodging
expenses are covered up to a 10,000 maximum
Transplant Services Services supplies drugs and aftercare for or related to artificial or non human organ implants or not covered transplants
Services that are considered experimental investigational or not medically necessary
Expenses for services which are specifically excluded under the Medical Expenses Not Covered
section of this plan
Transplants not listed as covered
PPO benefit not If you do not use a First Health National Transplant Program facility but you do use a PPO facil designated as ity 80 benefits will be applied to your expenses Total benefit payments including donor expens
National Transplant es the transplant procedure itself and transplant related follow up care for one year at the trans
rogram plant facility will be limited to a maximum payment of 150,000 for a liver transplant and 100,000 for any other transplant The travel and lodging allowance will not be available Charges incurred
for prescription drugs and follow up care outside of the transplant facility hospital will not be
counted toward this maximum
Cornea and pancreas transplants are not available through the First Health National Transplant
Program therefore the Travel Lodging Benefit is not available
Non PPO After the 300 non PPO calendar year deductible has been met the Plan pays 70 of reasonable benefit and customary charges for a covered surgical transplant performed in a non PPO facility up to a
maximum per transplant of 150,000 for a liver transplant and 100,000 for any of the other trans
plants listed on pages 15 16 Charges incurred for prescription drugs and follow up care outside of
the transplant facility hospital will not be counted toward this maximum
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
Precertification In order to receive benefits for the transplants listed above you are required to call First Health OnCall at 1 800 225 4423 as soon as the need for a transplant is discussed with your physician
When you call it will be necessary to provide the program with all information needed to complete
the review In order to receive the highest level of benefits all transplant related services must be
received at one of the designated hospitals within the First Health National Transplant Program
All covered transplant benefits including pre transplant evaluation expenses even if the transplant
does not occur will be provided by the Plan
If you do not follow the procedures required by the First Health National Transplant Program
the Plan s co payment will be reduced to the PPO or non PPO benefit level for all related covered
physician hospital expenses after any applicable deductible Also no coverage will be provided for
transportation or lodging and meal expenses if a transplant procedure is not performed at a First
Health National Transplant Program facility The penalty assessed when you do not follow the procedures required by the First Health National Transplant Program does not apply toward your
out of pocket maximum
Travel and If the recipient lives more than 100 miles from a designated transplant facility the Plan will pro lodging vide an allowance for pre approved travel and lodging expenses up to 10,000 per transplant The
allowance will not be subject to the calendar year deductible or coinsurance The allowance will
provide coverage of reasonable travel and temporary lodging expenses for the recipient and one
companion two companions of the recipient is a minor Covered travel and lodging expenses will
be established by the Plan s case manager during the precertification process Travel and lodging
to a designated facility for the pre transplant evaluation is covered under this benefit even if the
transplant is not eventually certified as medically necessary
Limitations For the purposes of the maximum total payment charges from doctors and hospitals while the patient is confined in a transplant facility will be counted toward the maximum Charges incurred
for prescription drugs and follow up care outside of the transplant facility hospital will not be
counted toward this maximum If the Plan cannot refer a member in need of a transplant to a First
Health National Transplant Program facility the 100,000 150,000 maximum will not apply
What is not Transplants not listed as covered covered
Mastectomy Women who undergo mastectomies may at their option have this procedure performed on an inpa surgery tient basis and remain in the hospital up to 48 hours after the procedure
Benefits will be provided for breast reconstruction surgery following a mastectomy including
surgery to produce a symmetrical appearance on the other breast Benefits will be provided for all
stages of breast reconstruction following a mastectomy including treatment of any physical complica
tions including lymphedemas and for breast prostheses including surgical bras and replacements
Pre surgical The Plan pays for laboratory tests pathology radiology and X rays directly related to the surgery testing when performed within 10 days prior to the surgery including the day of surgery when an outpa
tient or within 10 days prior to admission for inpatient surgery
Oral and Surgery by an oral surgeon for operations performed on the jaw for non dental oral surgery in the maxillofacial mouth including surgical correction of temporomandibular joint TMJ dysfunction
surgery Benefits are limited to the following procedures
Reduction of fractures of the jaws or facial bones
Reduction of dislocations and excision of TMJ joints
Surgical correction of cleft lip cleft palate or protruding mandible
Removal of stones from salivary ducts
Excision of tori leukoplakia or malignancies
Excision of ysts and incision of abscesses not involving teeth
Other procedures that do not involve a tooth structure alveolar process periodontal disease or
disease of gingival tissue
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
What is not Acupuncture except when used as an anesthetic agent for covered surgery covered Reversal of sterilization
Radial keratotomy
Cosmetic surgery as defined on page 38 except for the repair of accidental injuries sustained
while covered under the FEHBP Program
Treatment or removal of corns and calluses or trimming of toenails
Treatment of TMJ including dental appliances study models splint and other devices or ser
vices associated with the treatment of TMJ dysfunction except as provided for above
Maternity Benefits
What is covered The Plan pays the same benefits for hospital surgery delivery laboratory tests and other medical expenses as for illness or injury The mother at her option may remain in the hospital up to 48
hours after a regular delivery and 96 hours after a Cesarean delivery Inpatient stays will be extend
ed if medically necessary
Inpatient hospital Hospital bassinet or nursery charges for days on which the mother and child are both confined are considered other hospital charges of the mother and not charges of the child However when a new
born requires definitive treatment or evaluation for medical or surgical reasons during or after the
mother s confinement the newborn is considered a patient in his or her own right Under these cir
cumstances expenses of the newborn including incubation charges by reason of prematurity are
eligible for benefits only if the child is covered by a family enrollment
Precertification The medical necessity of your hospital admission should the admission exceed 48 hours after a reg ular vaginal delivery or 96 hours after a Cesarean delivery must be precertified for you to receive
full Plan benefits Unscheduled or emergency hospital admissions not precertified must be reported
within two business days following the day of admission even if you have been discharged Newborn
confinements that extend beyond the mother s discharge must also be precertified If any of the
above are not done the benefits payable will be reduced by 500 See pages 36 37 for details
Room and board
PPO After a 150 deductible per admission the Plan pays 90 of the charges covered under Inpatient benefit Hospital Benefits
Non PPO After a 250 deductible per admission the Plan pays 70 of the charges covered under Inpatient benefit Hospital Benefits
Other charges
PPO The Plan pays 90 of the charges covered under Inpatient Hospital Benefits benefit
Non PPO The Plan pays 70 of the charges covered under Inpatient Hospital Benefits benefit
Specialized The primary objective of specialized maternity services is to identify high risk pregnancies to pro maternity mote positive outcomes for the mother and baby and to assist in coordinating cost effective care
services You should call First Health s toll free number 1 800 225 4423 during the first trimester of your pregnancy At this time a nurse will ask you questions about your general health and medical his
tory This information will be discussed with your physician or practitioner to help determine the
risk factor of your pregnancy
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
If your pregnancy is classified as moderate or high risk First Health will follow your case recom
mend specialists and or facilities when applicable and coordinate communication among you and
your health care providers The specialized maternity program is an optional service provided for
your benefit The Plan s copayment will not be reduced if you choose not to participate in the pro
gram If you participate you will receive incentives which have been identified by your health plan
Outpatient care The Plan pays 100 of reasonable and customary charges for covered services rendered at the time of delivery when
Delivery is on an outpatient basis
Delivery is at a birthing center
The Plan pays 100 of reasonable and customary charges for two newborn pediatric visits within
five days of a birthing center or outpatient delivery
If the mother or the newborn child is transferred from a birthing center to a hospital due to med
ical complications the birthing center expenses will be paid at 100 of reasonable and customary
charges
Obstetrical care The Plan pays Surgical Benefits for obstetrical care see page 14 for delivery by a doctor or State licensed midwife and routine circumcision as part of the mother s maternity claim Delivery
includes associated obstetrical care anesthesia sonograms amniocentesis and related tests on the
unborn child
Benefits are provided for two routine newborn pediatric visits while the mother and child are both
confined
Benefits for pre and postnatal care rendered independently of delivery services are provided under
Other Medical Benefits
Procedures services drugs and supplies related to abortions are covered only when the life of the
mother would be endangered if the fetus were carried to term or when the pregnancy is the result
of an act of rape or incest
Related benefits
Diagnosis and Diagnosis and treatment of infertility except as described below is covered under Other Medical treatment of Benefits page 21
infertility
Voluntary See Surgical Benefits page 14 sterilization
Well child care See Additional Benefits page 25
For whom Benefits are payable under Self Only enrollments and for family members under Self and Family enrollments
What is not covered Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the
result of an act of rape or incest
Assisted Reproductive Technology ART procedures such as artificial insemination in vitro
fertilization embryo transfer and GIFT as well as services and supplies related to ART proce
dures are not covered
Reversal of voluntary surgical sterilization
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
Mental Conditions Substance Abuse
Benefits
What is covered The Plan pays for the following services
Mental conditions
Inpatient care After a 500 deductible per person per confinement the Plan will pay 80 of the PPO contracted rate for a PPO facility or reasonable and customary charges of a non PPO facility Benefits for inpatient
mental conditions will be limited to 45 days per person per calendar year The Plan provides benefits
for inpatient doctor visits as noted below in the Outpatient Care and Inpatient Visits provision
Precertification The medical necessity of your admission to a hospital or other covered facility must be precertified for you to receive full Plan benefits Emergency admissions must be reported within two business
days following the day of admission even if you have been discharged Otherwise the benefits
payable will be reduced by 500 See page 37 for details
Inpatient visits and PPO After the 100 PPO calendar year deductible has been met doctors visits Outpatient care benefit inpatient and outpatient for the treatment of mental conditions are paid at
50 of the PPO contracted rate
Non PPO After the 300 non PPO calendar year deductible has been met doctors visits benefit inpatient and outpatient for the treatment of mental conditions are paid at
50 of reasonable and customary charges
The maximum benefit for doctors visits inpatient and outpatient is limited to 45 visits PPO and
non PPO combined per person per calendar year These services are covered only when rendered
by a licensed M D a licensed clinical psychologist a clinical social worker or a licensed psychi
atric nurse Other Medical Benefits are available for related diagnostic laboratory X ray services
The medical management of mental conditions will be covered under this Plan s Other Medical
Benefits provisions Related drug costs will be covered under this Plan s Prescription Drug
Benefits and any costs for psychological testing or psychotherapy will be covered under this Plan s
Mental Conditions Benefits Office visits for the medical aspects of treatment do not count toward
the 45 outpatient Mental Conditions visit limit
Notification In order to maximize your benefit under this Plan you or your provider should call 1 800 225 4423 to provide notification of outpatient mental health care Through the notification process clinical
staff is available to help maximize your mental health benefits help ensure you are receiving med
ically necessary care as well as inform you of the level of benefit coverage you are eligible for
Substance abuse
Inpatient Care PPO After the 100 PPO calendar year deductible has been met the Plan pays 100 benefit of the PPO contracted rate for substance abuse treatment up to 4,000 annually
Non PPO After the 300 non PPO calendar year deductible has been met the Plan pays 80 benefit of reasonable and customary charges for substance abuse treatment up to 4,000
annually
Withdrawal prior to completion constitutes use of one program All professional fees associated
with the inpatient treatment program are included in the 4,000 maximum
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
Outpatient Care PPO After the 100 PPO calendar year deductible has been met outpatient doctors vis benefit its for the treatment of substance abuse are paid at 75 of the PPO contracted rate
Non PPO After the 300 non PPO calendar year deductible has been met outpatient doc benefit tors visits for the treatment of substance abuse are paid at 50 of reasonable and
customary charges
The maximum benefit for outpatient doctors visits for the treatment of substance abuse are limit
ed to 4,000 maximum per person per calendar year PPO and non PPO combined
Notification In order to maximize your benefit under this Plan you or your provider should call 1 800 225 4423 to provide notification of outpatient substance abuse treatment Through the notification process
clinical staff is available to help maximize your benefits help ensure you are receiving medically
necessary care as well as inform you of the level of benefit coverage you are eligible for
Lifetime maximum Benefits for inpatient substance abuse treatment are limited to 60 inpatient days per person per life time
What is not Any service rendered in relation to a learning disability covered
Treatment of mental conditions and substance abuse except as shown above
Other Medical Benefits
What is covered The Plan pays as follows
PPO After the 100 PPO calendar year deductible has been met the Plan pays 90 of the PPO con benefit tracted rate
Non PPO After the 300 non PPO calendar year deductible has been met the Plan pays 70 of reasonable benefit and customary charges
The Plan provides PPO and non PPO benefits for the services listed below
Doctors hospital visits
Services of an independent consulting doctor for a second opinion regarding the necessity for
anticipated surgery when not required by the Plan
Electroshock therapy
Diagnosis and treatment of infertility except as described on page 19
Hospital outpatient services and supplies when not covered under other benefit provisions of
this Plan
Allergy treatment including injections and testing
B 12 injections for a diagnosis of pernicious anemia
Drugs medical supplies appliances medical equipment and any covered item billed by a hos
pital but to be used at home
Interpretation fees billed by a radiologist or pathologist
Outpatient The Plan provides benefits for doctors outpatient services including office and home visits doctor s visits
PPO After the 10 copay per visit the Plan pays 100 of the PPO contracted rate for doctors visits and benefit the routine screening services listed below
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
21
21
21
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
Non PPO After the 300 non PPO calendar year deductible has been met the Plan pays 70 of reasonable benefit and customary charges
Routine services In addition to coverage on page 21 of diagnostic X rays laboratory and pathology services and machine diagnostic tests the following routine screening services are covered as preventive care
and are not subject to the deductible
Breast cancer Mammograms are covered for women age 35 and older as follows screening
From age 35 through 39 one mammogram screening during this five year period
From age 40 through 49 one mammogram screening every one or two consecutive calendar years
From age 50 through 64 one mammogram screening every calendar year
At age 65 and older one mammogram screening every two consecutive calendar years
Cervical cancer Annual coverage of one pap smear for women age 18 and older screening
Colorectal cancer Annual coverage of one fecal occult blood test for members age 40 and older screening
One screening sigmoidoscopy every five years for members age 50 and older
Prostate cancer Annual coverage of one PSA Prostate Specific Antigen test for men age 40 and older screening
Routine physical After the 10 PPO office visit copay the Plan pays up to a 150 maximum for charges made by PPO only a PPO doctor for one routine physical examination every 24 months
Sickle cell Screening of newborns for sickle cell anemia screening
Other services The Plan provides PPO and non PPO benefits for the services listed below
PPO After the 100 PPO calendar year deductible has been met the Plan pays 90 of the PPO con benefit tracted rate
Non PPO After the 300 non PPO calendar year deductible has been met the Plan pays 70 of reasonable benefit and customary charges
Dentists services including initial replacement repair and dental X rays due to accidental
injury to jaw or sound natural teeth Services must be received within 12 months from the date
of the accident
One pair of eyeglasses or contact lenses and examinations if required to correct an impairment
directly caused by accidental ocular injury or intraocular surgery and obtained within one year
Diagnostic procedures including laboratory tests X rays and tests such as electrocardiograms
basal metabolism readings CAT scans MRI s and electroencephalograms
Local professional ambulance service If special hospital treatment requiring special equipment
is necessary but not locally available the Plan also covers transportation within the United States
and Canada by professional ambulance railroad or scheduled commercial airlines to the near
est hospital equipped to furnish the treatment This benefit does not apply to transportation nec
essary to obtain the services of a doctor or any other practitioner
Rental or purchase at the option of the Plan of a hospital type bed wheelchair iron lung cer
tain types of traction equipment and other durable medical equipment as determined by the Plan
Chemotherapy radium radioactive isotopes and X ray therapy
Speech occupational and physical therapy visits to restore an attained bodily function or
speech when there has been a total or partial loss of bodily function or functional speech due
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
to illness or injury when the following conditions are met 1 the care is ordered by the attend
ing doctor 2 the doctor identifies the specific professional skills required by the patient and
the medical necessity for skilled services and 3 the doctor indicates the length of time the ser
vices are needed
Oxygen and rental of equipment for its administration
Artificial eyes and limbs to replace natural eyes and limbs
Blood or blood plasma when not donated or replaced and its administration
Renal dialysis not covered under Inpatient Hospital Benefits
Psychological testing
Limited benefits
Cardiac PPO After the 100 PPO calendar year deductible has been met the Plan pays 70 rehabilitation benefit of the PPO contracted rate
program
Non PPO After the 300 non PPO calendar year deductible has been met the Plan pays benefit 50 of reasonable and customary charges
Outpatient visits must consist of outpatient cardiac rehabilitative exercise education and counsel
ing Patients must be diagnosed as having angina pectoris chest pain or must have been hospital
ized for a diagnosed myocardial infarction heart attack or coronary surgery to be eligible for car
diac rehabilitation benefits
To be covered services must be provided by an approved hospital based or hospital coordinated
cardiac rehabilitation program Cardiac rehabilitation benefits are renewed by further hospital
admissions for diagnosed infarctions or coronary surgeries
Chiropractor PPO After the 100 PPO calendar year deductible has been met the Plan pays 90 benefit of the PPO contracted rate
Non PPO After the 300 non PPO calendar year deductible has been met the Plan pays benefit 70 of reasonable and customary charges
Benefits are limited to a maximum of 225 per person per calendar year PPO and non PPO com
bined for outpatient services rendered by a licensed chiropractor No other services of a chiro
practor are covered under any other provisions of this Plan
Childhood Childhood immunizations recommended by the American Academy of Pediatrics are covered for immunizations eligible members under age 22
Smoking cessation PPO After the 100 PPO calendar year deductible has been met smoking cessation benefit
benefit benefits are limited to 100 for one smoking cessation program per member per lifetime
Non PPO After satisfaction of the 300 non PPO calendar year deductible smoking ces benefit sation benefits are limited to 100 for one smoking cessation program per
member per lifetime
What is not Orthopedic shoes orthotics and other supportive devices for the feet covered Provocative food testing end point titration techniques and sublingual allergy desensitization
Preventive medical care and services except as shown under the routine services benefit and
well child care benefit including periodic checkups associated X ray and lab tests and immu
nizations such as polio flu mumps and smallpox shots
Chelation therapy except for acute arsenic gold lead or mercury poisoning
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
23
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
Weight control or any treatment of obesity unless obesity is caused by an organic condition
Nutritional supplements and vitamins except B 12 injections for pernicious anemia
Eye exercises and visual training orthoptics or visual therapy
Eyeglasses contact lenses or examinations for them when not specifically covered by this Plan
Hearing aids and examinations for them including hearing tests
Spare eyeglasses spare contact lenses replacement eyeglasses or replacement contact lenses
Routine mammograms for members under age 35
Charges for speech therapy physical therapy and occupational therapy related to services treat
ment educational testing or training related to learning disabilities or developmental delays
Additional Benefits
Accidental injury The Plan pays 100 of the PPO contracted rate or reasonable and customary charges incurred within 72 hours after an accidental injury for initial emergency treatment other than surgery pro
vided by a doctor and outpatient services furnished by a hospital Other Medical Benefits are avail
able for covered services and supplies provided for follow up care or care provided more than 72
hours after the accident
Medical emergency After the 25 copay for an emergency room visit the Plan pays 100 of the PPO contracted rate or reasonable and customary charges for initial treatment in the emergency room of a hospital as a
result of a medical emergency as defined on page 40 Other Medical Benefits are available for
covered services and supplies that are provided in a doctor s office or are not the result of a med
ical emergency
Round the clock The Alliance Health Benefit Plan has made available a program called First Health OnCall to support provide you with round the clock support You may call First Health OnCall s toll free number
1 800 225 4423 at any time of the day or night to obtain general health care information or to have
your questions about health care issues answered A nurse will provide you with information about
your condition self care and if necessary suggest the names of network providers from whom you
may seek health care
This 24 hour a day 7 day a week service is a benefit to you allowing you to be informed about
your health care options There is no penalty for not using it This service is not meant to replace
physician care If you require medical care please be sure to see your physician or practitioner
Home health care The Plan pays 100 up to 40 per visit for up to 60 home health care visits in a calendar year
A home health care visit consists of
1 Less than an 8 hour shift of nursing care or
2 One therapy session or
3 One social worker visit or
4 Less than an 8 hour shift by a home health aide
Covered home health care services are
Nursing care provided on a part time basis less than an 8 hour shift by
a a registered nurse RN or
b a licensed practical nurse LPN
Physical occupational or speech therapy provided by a licensed therapist
Services of a licensed social worker but not more than 2 visits
Home health aide services provided on a part time basis less than an 8 hour shift that
a are performed by a home health aide under the supervision of a registered nurse RN
and
b consist mainly of medical care and therapy provided solely for the care of the patient
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
The home health care services must be furnished
a by a home health care agency or by visiting nurses where services of a home health care
agency are not available
b in accordance with a home health care plan see definition on page 39 and
c in the patient s home
Hospice care
What is covered The Plan will pay 100 of reasonable and customary charges up to a maximum total payment of 4,500 for hospice care provided and billed by a licensed or certified hospice for a terminally ill
patient in the final stages of that illness when such care is recommended by a doctor This benefit
does not apply to services shown as covered under any other provisions of this Plan
What is not Bereavement counseling covered
Funeral arrangements
Pastoral counseling
Financial or legal counseling
Homemaker or caretaker services
Nursing services Benefits for services rendered out of a hospital by a registered graduate nurse R N or a licensed practical nurse L P N for private duty nursing are provided for a maximum of 240 units in a cal
endar year at 100 up to 15 per unit One private duty nursing unit consists of up to one hour of
private duty nursing care
Skilled nursing If a person is confined in a skilled nursing care facility the Plan will for a maximum of 60 days facilities after the deductible is met pay 80 of the reasonable and customary charges of the skilled nurs
ing care facility when
The confinement begins within 14 days after a covered hospitalization of at least 3 days
The confinement is for the purpose of receiving care for the condition which caused the
hospitalization and
The confinement is under the supervision of a doctor
Skilled nursing facility benefits shown above will be restored for each new period of confinement
There is a new period of confinement when
The provisions for coverage listed above are met and
At least 60 days have elapsed since the patient was last confined in a skilled nursing facility
Well child care The Plan provides coverage for 12 well child care visits including doctors visits and routine screening services for children up to and including age 6 when covered under a Self and
Family enrollment
PPO After a 10 copay per visit the Plan pays 100 of the contracted rate benefit
Non PPO After the 300 non PPO calendar year deductible has been met the Plan pays 70 of reasonable benefit and customary charges
Immunizations The Plan will pay 100 of reasonable and customary charges not subject to a deductible for the following immunizations for dependent children under age 22 DPT diphtheria tetanus pertussis
vaccine OPV oral polio vaccine Hepatitis B vaccine Haemophilis influenza type b vaccine flu
shot MMR measles mumps rubella vaccine and Td tetanus diphtheria toxoid booster
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
Prescription Drug Benefits
What is covered The following medications and supplies when prescribed by a licensed physician may be pur chased from either a retail pharmacy or through the mail service pharmacy
Drugs that by Federal law of the United States require a doctor s prescription for their purchase
Insulin
Diabetic diagnostic supplies used to test blood and urine for glucose levels
Needles and syringes for the administration of covered medications
Full range of FDA approved drugs prescriptions and devices for birth control
What is not covered Medical supplies such as dressings and antiseptics Medication that does not require a prescription under Federal law even if your doctor prescribes
it or a prescription is required under your State law
Drugs to aid in smoking cessation except those limited to the 100 lifetime maximum as part
of the smoking cessation benefit see page 23
Drugs related to treatment of sexual dysfunction sexual inadequacy or sexual transformation
Drugs that are investigational or experimental
Drugs prescribed for weight loss
Vitamins and nutritional supplements
Drugs and supplies for cosmetic purposes
From a pharmacy Annual prescription drug deductible Under this program there is a combined annual prescription drug deductible of 200 per covered person for prescriptions filled through the retail and or mail
service programs
articipating Your Cost After the annual prescription drug deductible has been met you pay a 10 copay for the pharmacies initial prescription for up to a 30 day supply of medication as prescribed by your doctor and 10
each for the first and second refills After that for the third and any subsequent refills the cost
increases to 50 of Alliance s negotiated price for the medication
Keeping your costs down use generic drugs In addition if you request a brand name when there
is a generic equivalent available and your doctor has not required that the brand name drug be dis
pensed you will be required to pay the difference in price between the brand name drug and the
generic drug plus the copayment Any deductible copayments or costs you are required to pay if
you purchase a brand name drug when a generic equivalent is available and your doctor has not
indicated that the brand name drug must be dispensed will not be reimbursed by the Plan and do
not count toward the catastrophic protection benefit
If your doctor prescribes a medication that will be taken over an extended period you should request
two prescriptions the first for up to a 30 day supply that can be filled at a local participating phar
macy and second for up to a 90 day supply plus refills that can be filled through the mail service pro
gram The mail service program offers cost savings on long term medications
Wai ve r There is no waiver of the 200 deductible for enrollees with Medicare Part B when you use the retail and or mail order program
Prescription drug Under the prescription drug card program you will be issued an Alliance First Health Rx card program identification card Present this card at a participating retail pharmacy whenever purchasing
prescription medications The pharmacist will use an electronic system to verify your eligibil
ity for coverage and tell you the copayment and any annual deductible you will be responsible
for paying To locate a participating pharmacy near your home or workplace call Member
Services at 1 800 225 4423
Non participating After a combined retail and or mail order 200 annual prescription drug deductible per person pharmacy you pay a 10 copay per prescription or refill for the initial 30 day supply and two refills The
third and subsequent refills will require that you pay 50 of the cost of the prescription drug You
will also be responsible for any charges in excess of the participating pharmacy charges You must
pay the full amount of the prescription drug and file a claim to First Health Rx as indicated below
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
To claim If a participating pharmacy is not available where you reside or if you do not use your prescription benefits drug identification card you must pay in full for your medication obtain a prescription drug receipt
and submit a claim to
Alliance Health Benefit Plan Prescription Drug Program
First Health Rx Post Office Box 85042
Richmond VA 23261 5042
Reimbursement will be based on Plan cost had you used a participating pharmacy The Alliance s
cost represents a negotiated fee The actual cost to Alliance may be less than the retail price so your
reimbursement may be less
By mail
The mail service The Mail Service Pharmacy Program is administered by Merck Medco Managed Care L L C pharmacy program through its subsidiary Merck Medco Rx Services provider of the mail service pharmacy program
This program is designed for medications you take on a long term basis
After satisfying your combined annual 200 per person prescription drug deductible the Plan will
pay 80 of the covered charges per generic medication or per brand name medication
Keeping your costs down use generic drugs If you request a brand name drug when there is a
generic equivalent available and your doctor has not required that the brand name drug be dis
pensed you will be required to pay the difference in price between the brand name drug and the
generic drug plus the 20 coinsurance Any deductible copayments or costs you are required to
pay if you purchase a brand name drug when a generic equivalent is available and your doctor
has not indicated that the brand name drug must be dispensed will not be reimbursed by the Plan
and do not count toward the catastrophic protection benefit
To claim your It is easy to order your medications from Merck Medco Rx services benefits Here s how 1 Ask your doctor to prescribe needed medication for up to a 90 day supply of med
ication plus refills if appropriate Please note first time prescriptions will be limited to a 45 day
supply 2 Complete the Patient Profile Questionnaire the first time you order under this program
Mail the questionnaire your original prescription s to Merck Medco Rx Services in the special
mail order envelope You will be billed for the 20 coinsurance per generic medication and per
brand name medication Your billed 20 coinsurance will be due upon receipt Be certain to com
plete all of the information requested on the envelope 3 Refilling your medication To be sure you
never run short of your prescription medication you should re order on or after the refill date indi
cated on the refill slip or when you have fewer than 14 days of medication left
To order refills Call Member Services at 1 800 346 1321 and use the automated refill system Have your member by phone ID number and refill slip with the prescription information ready
To order Simply mail your prescription or refill slip in the special order envelope Send all to by mail
Merck Medco Rx Services
P O Box 650322
Dallas TX 75265 0322
If you have any questions about your mail order prescription call First Health Rx Services toll free
at 1 800 225 4423 Service is available 24 hours a day 7 days a week
To order You may order mail service prescriptions or check the status of your mail service prescription by Internet request prescription drug claim forms and mail service envelopes via the Internet at
http www merck medco com To check the status of your mail service prescription or to order
mail service prescription refills you must enter your member number and the prescription number
Please have your prescription bottle or refill slip handy when utilizing the Internet
Wai ve r There is no waiver of the 200 deductible for enrollees with Medicare Part B when you use the retail and or mail order program
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Section 5 Benefits continued
Dental Benefits
What is covered The following are the dental benefits for the Metlife Dental Program for In Network Preferred Providers and Out of Network non Preferred Providers For Out of Network services the plan
will pay the indicated coinsurance of the reasonable and customary allowance For questions
regarding dental claims or if you would like to request a listing of providers please call 1 800 942
0854 for assistance
In Network Out of Networ
Preferred Non Preferred
Annual Deductible 0 25 per individual
50 per family
Services Plan Pays Plan Pays
Preventive
Cleanings 100 90
Exams 100 90
Fluoride Treatments 100 90
Sealants 100 90
Diagnostic X Rays 100 90
Basic Restorative Care
Fillings 80 70
Annual Benefit Maximum 500 500
Per Person Combined In Networand
Out of Network
Related benefits
Accidental injury Other Medical Benefits page 22 are available for dentists services including initial replacement repair and dental X ray due to accidental injury to the jaw or sound natural teeth Services must
be received within 12 months from the date of the accident
Oral and For covered oral surgery see page 17 maxillofacial
surgery
What is not Dental extractions including the removal of impacted teeth covered
All dental services and appliances not listed above
Periodontal prophylaxis
Emergency exams
Charges in excess of the combined annual benefit maximum
The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you
use a PPO provider When no PPO provider is available non PPO benefits apply
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Alliance Health Benefit Plan 2000
Non FEHB Benefits Available to Plan Members
Enrollment in the Alliance Insurance Programs listed below is not a requirement for participation in the Alliance Health Benefit Plan These benefits are offered on a voluntary basis through carriers other than the Health Plan The
Alliance Health Benefit Plan is not responsible for any services or representations made by these carriers outside of these Alliance Insurance Programs
PLAN FEATURES NO CLAIM FORMS
CIGNA Dental Health No deductibles
Dental Plan No maximums
100 Coverage Diagnostic and Preventive Care Exams X rays
Cleanings
50 Coverage Basic Restorative Care Fillings Periodontics
Endodontics Simple Extractions
50 Coverage Major Restorations Onlays Dentures Crowns
Bridgework
Call 1 800 367 1037
AFLAC
American Family Life Accident Sickness Disability Hospital Intensive Care Cancer
Assurance Company of Insurance Policy
Columbus These policies provide benefits paid directly to you unless assigned that
can help you with your non medical expenses
Call 1 800 992 3522 and TDD 1 800 622 2345 or en espaol 1 800 742 3522
For policies available to residents of CT MA NJ and NY call 1 800 366 3436 for more information
Wal Mart From the nation s leading discount retailer discount prescription
Pharmacy Mail services for any family member whether or not a dependent
Services No annual fees or deductibles
Call 1 800 321 0347 for more information
Call 1 800 321 0347 for General Information
BENEFITS ON THIS AGE ARE NOT ART OF THE FEHB CONTRACT
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Alliance Health Benefit Plan 2000
Section 6 How to file a claim
How to Claim Benefits
Claim forms If you do not receive your identification card s within 60 days after the effective date of your identification cards enrollment call the Carrier at 1 800 225 4423 to report the delay In the meantime use your copy
and questions of the SF 2809 enrollment form or your annuitant confirmation letter from OPM as proof of enroll ment when you obtain services This is also the number to call for claim forms or advice on filing
claims
If you have a question concerning Plan benefits contact the Carrier at l 800 321 0347 or you may
write to the Carrier at Alliance Health Benefit Plan 1628 11th Street NW Washington DC 20001
You may also contact the Carrier by fax at 202 939 6389 at its website at http www ahbp com or
by e mail at ahbp patriot net
If you made your open season change by using Employee Express and have not received your new
ID card by the effective date of your enrollment call the Employee Express HELP number to
request a confirmation letter Use that letter to confirm your new coverage with providers
How to file Claims filed by your doctor that include an assignment of benefits to the doctor are to be filed on claims the form HCFA 1500 Health Insurance Claim Form Claims submitted by enrollees may be sub
mitted on the HCFA 1500 or a claim form that includes the information shown below Bills and
receipts should be itemized and show
Name of patient and relationship to enrollee
Plan identification number of the enrollee
Name and address of person or firm providing the service or supply
Dates that services or supplies were furnished
Type of each service or supply and the charge
Diagnosis
In addition
A copy of the explanation of benefits EOB from any primary payer such as Medicare must
be sent with your claim
Bills for private duty nurses must show that the nurse is a registered or licensed practical nurse
and must include nursing notes
Claims for rental or purchase of durable medical equipment private duty nursing and physical
occupational and speech therapy require a written statement from the doctor specifying the
medical necessity for the service or supply and the length of time needed
Claims for prescription drugs and medicines that are not ordered through the mail order drug
program or purchased with the prescription card must include receipts that include the pre
scription number name of drug prescribing doctor s name date and charge
Claims for overseas foreign services should include an English translation Charges should be
converted to U S dollars using the exchange rate applicable at the time the expense was incurred
Canceled checks cash register receipts or balance due statements are not acceptable
After completing a claim form and attaching proper documentation send claims to
Alliance Health Benefit Plan
First Health P O Box 22410
Tucson AZ 85734
Records Keep a separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to each person Save copies of all medical bills including
those you accumulate to satisfy a deductible In most instances they will serve as evidence of your
claim The Carrier will not provide duplicate or year end statements
Submit claims You are strongly encouraged to file your claims within 12 months of the date the service was ren promptly dered All claims must be received by the Plan no later than 24 months after the date of service
Claims for Other Medical Benefits preferably should not be submitted more than once per month
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Alliance Health Benefit Plan 2000
Section 6 How to file a claim continued
No claims will be considered if received more than 24 months after the date of service unless time
ly filing was prevented by administrative operations of Government or legal incapacity provided
the claim was submitted as soon as reasonably possible Once benefits have been paid there is a
three year limitation on the reissuance of uncashed checks
If the Plan returns a claim or part of a claim for additional information it must be resubmitted with
in 90 days or within 24 months after the date of service whichever is later
A finding of custodial care does not preclude benefits for all covered services and supplies Some
services such as prescription drugs X rays and laboratory may still be covered All bills should
be routinely submitted to the Plan for consideration
Direct payment to Claims for services rendered and submitted by a hospital will be paid directly to the hospital unless hospital or provider the bill is clearly marked paid or is accompanied by an official receipt for payment You may autho
of care rize direct payment to any other provider of care by signing the assignment of benefits section at the bottom of the claim form or by using the assignment form furnished by the provider of care
The provider of care s tax identification number must accompany the claim The Plan reserves the
right to make payment directly to the enrollee and to decline to honor the assignment of payment
of any health benefits claim to any person or party
Submit hospital and doctor bills itemized to show
Name of the person for whom service was rendered
Name of the attending doctor and or admitting hospital and address
Date charge was incurred statement of the diagnosis treatment rendered and amount of the
charge for each service
When more Reply promptly when the Carrier requests information in connection with a claim If you do not information is respond the Carrier may delay processing or limit the benefits available
needed
Section 7 General exclusions Things we don t cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless we
determine it is medically necessary to prevent diagnose or treat your illness or condition The fact that one of our providers has pre
scribed recommended or approved a service or supply does not make it medically necessary or eligible for coverage under this Plan
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric prac
tice in the United States
Experimental or investigational procedures treatments drug or devices
Procedures services drugs and supplies related to abortions except when the life of the moth
er would be endangered if the fetus were carried to term or when the pregnancy is the result of
an act of rape or incest
Procedures services drugs and supplies related to sex transformation sexual dysfunction or
sexual inadequacy
Services or supplies you receive from a provider or facility barred from the FEHB Program
Expenses you incurred while you were not enrolled in this Plan
Services and supplies when furnished without charge while in active military service or
required for illness or injury sustained on or after the effective date of enrollment 1 as a result
of an act of war within the United States its territories or possessions or 2 during combat
Services and supplies when furnished by immediate relatives or household members such as
spouse parent child brother or sister by blood marriage or adoption
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Alliance Health Benefit Plan 2000
Section 7 General exclusions Things we don t cover continued
Services and supplies when furnished or billed by a non covered facility except that medical
ly necessary prescription drugs are covered
Services and supplies not specifically listed as covered
Any portion of a provider s fee or charge ordinarily due from the enrollee but that has been
waived If a provider routinely waives does not require the enrollee to pay a deductible copay
or coinsurance the Carrier will calculate the actual provider fee or charge by reducing the fee
or charge by the amount waived
Charges the enrollee or Plan has no legal obligation to pay such as excess charges for an annu
itant age 65 or older who is not covered by Medicare Parts A and or B see page 35 doctor
charges exceeding the amount specified by the Department of Health and Human Services
when benefits are payable under Medicare limiting charge see page 34 or State premium
taxes however applied
Biofeedbac
Dental services and appliances except as specified on page 28
Exercise equipment whirlpool baths sunlamps heating pads air conditioners humidifiers
dehumidifiers and purifiers
Services and supplies to the extent the charge exceeds reasonable and customary charges
Services by practitioners who do not meet the definition of covered provider and
Charges for a stand by doctor
Section 8 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and will coordinate the payments On occasion
you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you
later want to re enroll in the FEHB Program generally you may do so only at the next open season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may re
enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and
your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration
SSA office or call SSA at 1 800 683 6833
This Plan and Medicare
Coordinating The following information applies only to enrollees and covered family members who are entitled benefits to benefits from both this Plan and Medicare You must disclose information about Medicare cov
erage including your enrollment in a Medicare prepaid plan to this Carrier this applies whether
or not you file a claim under Medicare You must also give this Carrier authorization to obtain
information about benefits or services denied or paid by Medicare when they request it It is also
important that you inform the Carrier about other coverage you may have as this coverage may
affect the primary secondary status of this Plan and Medicare see page 33
This Plan covers most of the same kinds of expenses as Medicare Part A hospital insurance and
Part B medical insurance except that Medicare does not cover prescription drugs
32
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Alliance Health Benefit Plan 2000
Section 8 Limitations Rules that affect your benefits continued
The following rules apply to enrollees and their family members who are entitled to benefits from
both a FEHB plan and Medicare
This Plan is 1 You are age 65 or over have Medicare Part A or Parts A and B and are employed by the Federal primary if Government
2 Your covered spouse is age 65 or over and has Medicare Part A or Parts A and B and you are
employed by the Federal Government
3 The patient you or a covered family member is within the first 30 months of eligibility to
receive Medicare Part A benefits due to End Stage Renal Disease ESRD except when Medicare
based on age or disability was the patient s primary payer on the day before he or she became eli
gible for Medicare Part A due to ESRD or
4 The patient you or a covered family member is under age 65 and eligible for Medicare solely
on the basis of disability and you are employed by the Federal Government
For purposes of this section employed by the Federal Government means that you are eligible
for FEHB coverage based on your current employment and that you do not hold an appointment
described under Rule 6 of the following Medicare is primary section
Medicare is 1 You are an annuitant age 65 or over covered by Medicare Part A or Parts A and B and are not primary if employed by the Federal Government
2 Your covered spouse is age 65 or over and has Medicare Part A or Parts A and B and you are
not employed by the Federal Government
3 You are age 65 or over and a you are a Federal judge who retired under title 28 U S C b you
are a Tax Court judge who retired under Section 7447 of title 26 U S C or c you are the cov
ered spouse of a retired judge described in a or b
4 You are an annuitant not employed by the Federal Government and either you or a covered fam
ily member who may or may not be employed by the Federal Government is under age 65 and
eligible for Medicare on the basis of disability
5 You are enrolled in Part B only regardless of your employment status
6 You are age 65 or over and employed by the Federal Government in an appointment that excludes
similarly appointed nonretired employees from FEHB coverage and have Medicare Part A or
Parts A and B
7 You are a former Federal employee receiving workers compensation and the Office of Workers
Compensation has determined that you are unable to return to duty
8 The patient you or a covered family member has completed the 30 month ESRD coordination
period and is still eligible for Medicare due to ESRD or
9 The patient you or a covered family member becomes eligible for Medicare due to ESRD after
Medicare assumed primary payer status for the patient under rules 1 through 7 above
When Medicare When Medicare is primary all or part of your Plan deductibles and coinsurance will be waived as is primary follows
Inpatient Hospital Benefits If you are enrolled in Medicare Part A the Plan will waive the deductible and coinsurance
Surgical Benefits If you are enrolled in Medicare Part B the Plan will waive the deductible and coinsurance
Mental Conditions Substance Abuse Benefits If you are enrolled in Medicare Part A the Plan will waive the deductible and coinsurance for inpatient care If you are enrolled in Medicare Part
B the Plan will waive the deductible and coinsurance for outpatient care
Other Medical Benefits If you are enrolled in Medicare Part B the Plan will waive the deductible and coinsurance for medical benefits
When Medicare is the primary payer this Plan will limit its payment to an amount that supplements
the benefits that would be payable by Medicare regardless of whether or not Medicare benefits are
paid However the Plan will pay its regular benefits for emergency services to an institutional
provider such as a hospital that does not participate with Medicare and is not reimbursed by Medicare
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Alliance Health Benefit Plan 2000
Section 8 Limitations Rules that affect your benefits continued
If you are enrolled in Medicare you may be asked by a physician to sign a private contract agree
ing that you can be billed directly for services that would ordinarily be covered by Medicare
Should you sign such an agreement Medicare will not pay any portion of the charges and you may
receive less or no payment for those services under this Plan
When you also When you are enrolled in a Medicare prepaid plan while you are a member of this Plan you may enroll in a Medicare continue to obtain benefits from this Plan If you submit claims for services covered by this Plan
prepaid plan that you receive from providers that are not in the Medicare plan s network the Plan will not waive any deductibles or coinsurance when paying these claims
Medicare s If you are covered by Medicare Part B and it is primary you should be aware that your out of pock payment and et costs for services covered by both this Plan and Medicare Part B will depend on whether your
this Plan doctor accepts Medicare assignment for the claim
Doctors who participate with Medicare accept assignment that is they have agreed not to bill you
for more than the Medicare approved amount for covered services Some doctors who do not par
ticipate with Medicare accept assignment on certain claims If you use a doctor who accepts
Medicare assignment for the claim the doctor is permitted to bill you after the Plan has paid only
when the Medicare and Plan payments combined do not total the Medicare approved amount
Doctors who do not participate with Medicare are not required to accept direct payment or assign
ment from Medicare Although they can bill you for more than the amount Medicare would pay
Medicare law the Social Security Act 42 U S C sets a limit on how much you are obligated to
pay This amount called the limiting charge is 115 percent of the Medicare approved amount
Under this law if you use a doctor who does not accept assignment for the claim the doctor is per
mitted to bill you after the Plan has paid only if the Medicare and Plan payments combined do not
total the limiting charge Neither you nor your FEHB Plan is liable for any amount in excess of the
Medicare limiting charge for charges of a doctor who does not participate with Medicare The
Medicare Summary Notice MSN form will have more information about this limit
If your doctor does not participate with Medicare asks you to pay more than the limiting charge and
he or she is under contract with this Plan call the Plan If your doctor is not a Plan doctor ask the
doctor to reduce the charge or report him or her to the Medicare carrier that sent you the Medicare
MSN form In any case a doctor who does not participate with Medicare is not entitled to payment
of more than 115 percent of the Medicare approved amount
How to claim In most cases when services are covered by both Medicare and this Plan Medicare is the primary benefits payer if you are an annuitant and this Plan is the primary payer if you are an employee When
Medicare is the primary payer your claims should first be submitted to Medicare The Carrier has
contracted with most Medicare Part B claims processors also known as carriers to receive elec
tronic copies of your claims after Medicare has paid their benefits This means you do not need to
submit your Part B claims to the claims processor Call the Carrier at 1 800 225 4423 to find out
if your claims are being filed electronically If they are not you should initially submit your claims
to Medicare After Medicare has paid its benefits the Carrier will consider the balance of any cov
ered expenses To be sure your claims are processed by this Carrier you must submit the MSN form
from Medicare and duplicates of all bills along with a completed claim form The Carrier will not
process your claim without knowing whether you have Medicare and if you do without receiving
the Medicare MSN
Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance coverage You must tell us if you or a family member has double coverage You must also send us documents
about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan
is secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines
If we pay second we will determine how much of the charge we will pay for After the first plan
pays we will pay either what is left of the reasonable charge or our regular benefit whichever is
less We will not pay more than the reasonable charge
Remember Even if you do not file a claim with your other plan you must still tell us that you have
double coverage
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Section 8 Limitations Rules that affect your benefits continued
When others are Subrogation applies when you are sick or injured as a result of the act or omission of another per responsible for injuries son or party Subrogation means the Plan s right to recover any benefit payments made to you or
your dependent by a third party s insurer because of an injury or illness caused by the third party
Third party means another person or organization
If you or your dependent receive Plan benefits and have a right to recover damages from a third
party the Plan is subrogated to this right All recoveries from a third party whether by lawsuit set
tlement or otherwise must be used to reimburse the Plan for benefits paid Any remainder will be
yours or your dependent s The Plan s share of the recovery will not be reduced because you or your
dependent has not received full damages claimed unless the Plan agrees in writing to a reduction
You must promptly advise the Plan whenever a claim is made against a third party with respect to
any loss for which the Plan benefits have been or will be paid You or your dependent must execute
any assignments liens or other documents and provide information as the Plan request Plan ben
efits may be withheld until documents or information is received
If you need more information about subrogation the plan will provide you with its subrogation pro
cedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the mili tary TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we
are the primary payer See your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage
Workers We do not cover services that compensation
You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must pro
vide
OWCP or a similar agency pays for through a third party injury settlement or other similar pro
ceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will pro
vide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or Agencies indirectly pays for
Overpayments The Carrier will make reasonably diligent efforts to recover benefit payments made erroneously but in good faith and may apply subsequent benefits otherwise payable to offset any overpayments
Limits on your cost if you The information in the following paragraphs applies to you when 1 you are not covered by either are age 65 or older and Medicare Part A hospital insurance or Part B medical insurance or both 2 you are enrolled in
don t have Medicare this Plan as an annuitant or as a former spouse or family member covered by the family enrollment of an annuitant or former spouse and 3 you are not employed in a position which confers FEHB
coverage
Inpatient If you are not covered by Medicare Part A are 65 or older or become age 65 while receiving inpa hospital tient hospital services and you receive care in a Medicare participating hospital the law 5 U S C
care 8904 b requires the Plan to base its payment on an amount equivalent to the amount Medicare would have allowed if you had Medicare Part A This amount is called the equivalent Medicare
amount After the Plan pays the law prohibits the hospital from charging you for covered services after you have paid deductibles coinsurance or copayments you owe under the Plan Any coinsur
ance you owe will be based on the equivalent Medicare amount not the actual charge You and the
Plan together are not legally obligated to pay the hospital more than the equivalent Medicare
amount
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Alliance Health Benefit Plan 2000
Section 8 Limitations Rules that affect your benefits continued
The Carrier s explanation of benefits EOB will tell you how much the hospital can charge you in
addition to what the Plan paid If you are billed more than the hospital is allowed to charge ask the
hospital to reduce the bill If you have already paid more than you have to pay ask for a refund If
you cannot get a reduction or refund or are not sure how much you owe call Alliance Health
Benefit Plan at 1 800 321 0347 for assistance
Physician Claims for physician services provided for retired FEHB members age 65 and older who do not services have Medicare Part B are also processed in accordance with 5 U S C 8904 b This law mandates
the use of Medicare Part B limits for covered physician services for those members who are not
covered by Medicare Part B
The Plan is required to base its payment on the Medicare approved amount which is the Medicare
fee scheduled for the service or the actual charge whichever is lower If your doctor is a member
of the Plan s preferred provider organization PPO and participates with Medicare the Plan will
base its payment on the lower of these two amounts and you are responsible only for any deductible
and the PPO copayment or coinsurance
If you go to a PPO doctor who does not participate with Medicare you are responsible for any
deductible and the copayment or coinsurance In addition unless the doctor s agreement with the
Carrier specifies otherwise you must pay the difference between the Medicare approved amount
and the limiting charge 115 of the Medicare approved amount
If your physician is not a Plan PPO doctor but participates with Medicare the Plan will base its
regular benefit on the Medicare approved amount For instance under this Plan s surgery benefit
the Plan will pay 70 of the Medicare approved amount You will only be responsible for any
deductible and coinsurance equal to 30 of the Medicare approved amount
If your physician does not participate with Medicare the Plan will still base its payment on the
Medicare approved amount However in most cases you will be responsible for any deductible the
coinsurance or copayment amount and any balance up to the limiting charge amount 115 of the
Medicare approved amount
Since a physician who participates with Medicare is only permitted to bill you up to the Medicare
fee schedule amount even if you do not have Medicare Part B it is generally to your financial
advantage to use a physician who participates with Medicare
The Carrier s explanation of benefits EOB will tell you how much the physician can charge you
in addition to what the Plan paid If you are billed more than the physician is allowed to charge asthe
physician to reduce the bill If you have already paid more than you have to pay ask for a
refund If you cannot get a reduction or refund or are not sure how much you owe call the Alliance
Health Benefit Plan at 1 800 321 0347 for assistance
Section 9 Fee for Service facts
Precertification First Health may review a proposed service to determine whether it is medically necessary If it is determined to be medically necessary you and your physician will receive a Notice of Certification
If services are proposed to extend beyond the period for which precertification is given First Health
will initiate medical necessity reassessment prior to the receipt of additional services
You are required to call First Health s toll free number at 1 800 225 4423 for the following
All inpatient admissions other than maternity including any elective admission to a hospital
Within 48 hours 2 working days of any emergency admission
When a maternity stay extends beyond 48 hours following a normal vaginal delivery or 96 hours
following a Caesarean section delivery
You may call at any time day or night When you call it will be necessary to provide First Health
with your name the patient s name the name of the physician and hospital or facility the reason
for the hospitalization and any other information needed to complete the review You will be
advised if precertification of medical necessity is required for the proposed services If so the pre
certification process will be started immediately When the above requirements are met First
Health will tell the doctor and hospital the number of certified days of confinement for the care of the patient s condition
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Alliance Health Benefit Plan 2000
Section 9 Fee for Service facts continued
Precertification is not a guarantee that benefits are payable by this plan Also precertification does
not substitute for filing a claim with the plan if necessary Payment of benefits is subject to all plan
provisions limitations and exclusions In addition verification of coverage neither fulfills precer
tification requirements nor guarantees payment of benefits If you are uncertain about whether pre
certification is required for proposed services call First Health s toll free number 1 800 225
4423 It is your responsibility to complete the precertification process If precertification is not
made and benefits are otherwise payable benefits for the admission will be reduced by 500
Need additional First Health will contact your doctor before the certified length of stay ends to determine if you days will be discharged on time or if additional inpatient days are medically necessary If the admission
is precertified but you remain confined beyond the number of days certified as medically neces
sary the Plan will not pay for charges incurred on any extra days that are deemed by the Carrier
not to be medically necessary
You don t need to certify Medicare Part A or another group health insurance policy is the primary payer for the hospital con an admission when finement see page 33 Precertification is required however when Medicare hospital benefits are
exhausted prior to using lifetime reserve days
You are confined in a hospital outside the United States or Puerto Rico
Maternity or When there is an unscheduled maternity admission that extends beyond 48 hours following a nor emergency mal vaginal delivery or 96 hours following a caesarean section delivery or an emergency admission
admissions due to a condition that puts the patient s life in danger or could cause serious damage to bodily func tion you your representative the doctor or the hospital must telephone 1 800 225 4423 within two
business days following the day of admission even if the patient has been discharged from the hos
pital Otherwise inpatient benefits otherwise payable for the admission will be reduced by 500
Newborn confinements that extend beyond the mother s discharge date must also be certified You
your representative the doctor or hospital must request certification for the newborn s continued
confinement within 48 hours two business days following the day of the mother s discharge
Other An early determination of need for confinement precertification of the medical necessity of inpa considerations tient admission is binding on the Carrier unless the Carrier is misled by the information given to
it After the claim is received the Carrier will first determine whether the admission was precerti
fied and then provide benefits according to all of the terms of this brochure
If you do not If precertification is not obtained before admission to the hospital or within two business days fol precertify lowing an emergency admission or in the case of a newborn the mother s discharge a medical
necessity determination will be made at the time the claim is filed If the Carrier determines that
the hospitalization was not medically necessary the inpatient hospital benefits will not be paid
However medical supplies and services otherwise payable on an outpatient basis will be paid
If the claim review determines that the admission was medically necessary any benefits payable
according to all of the terms of this brochure will be reduced by 500 for failing to have the admis
sion precertified
If the admission is determined to be medically necessary but part of the length of stay was found
not to be medically necessary inpatient hospital benefits will not be paid for the portion of the con
finement that was not medically necessary However medical services and supplies otherwise
payable on an outpatient basis will be paid
Protection Against Catastrophic Costs
Catastrophic For those services with coinsurance the Plan pays 100 of reasonable and customary charges for protection the remainder of the calendar year after the calendar year deductible is met when out of pocket
expenses for coinsurance in that calendar year exceed 2,000 under the PPO benefit The Plan pays
100 of reasonable and customary charges if out of pocket expenses for the coinsurance in that
calendar year exceed 3,000 under the non PPO benefit Any expenses incurred through PPO or
non PPO benefits are applied toward both catastrophic limits
Out of pocket expenses for the purposes of this benefit are
The 100 calendar year deductible for PPO benefits
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Alliance Health Benefit Plan 2000
Section 9 Fee For Service Facts continued
The 300 calendar year deductible for non PPO benefits
The 150 PPO per admission inpatient hospital deductible
The 250 non PPO per admission inpatient hospital deductible
The 10 you pay for PPO hospital surgical maternity and other medical benefits
The 30 you pay for non PPO hospital surgical maternity and other medical benefits
The following cannot be counted toward out of pocket expenses
Expenses in excess of reasonable and customary charges or maximum benefit limitations
Expenses for mental conditions substance abuse or dental care
Any amounts you pay because benefits have been reduced for non compliance with this Plan s
cost containment requirements see page 37
PPO office visit copayments
Expenses for prescription drugs purchased through retail or mail order program and
Expenses for skilled nursing facility confinements
Carryover If you changed to this Plan during open season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1 any expenses that would have applied to
that plan s catastrophic protection benefit during the prior year will be covered by your old plan if
they are for care you got in January before the effective date of your coverage in this Plan If you
have already met the covered out of pocket maximum expense level in full your old plan s cata
strophic protection benefit will continue to apply until the effective date If you have not met this
expense level in full your old plan will first apply your covered out of pocket expenses until the
prior year s catastrophic level is reached and then apply the catastrophic protection benefit to cov
ered out of pocket expenses incurred from that point until the effective date The old plan will pay
these covered expenses according to this year s benefits benefit changes are effective on January 1
Definitions
Accidental injury An injury caused by an external force such as a blow or a fall and which requires immediate med ical attention Also included are animal bites poisonings and dental care required as a result of
accidental injury to sound natural teeth An injury to teeth while eating is not considered to be an
accidental injury
Admission The period from entry admission into a hospital or other covered facility until discharge In count ing days of inpatient care the date of entry and the date of discharge are counted as the same day
Assignment An authorization by an enrollee or spouse for the Carrier to issue payment of benefits directly to the provider The Carrier reserves the right to pay the member directly for all covered services
Calendar year January 1 through December 31 of the same year For new enrollees the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year
Congenital A condition existing at or from birth which is a significant deviation from the common form or anomaly norm For purposes of this Plan congenital anomalies include protruding ear deformities cleft lips
cleft palates birthmarks webbed fingers or toes and other conditions that the Carrier may deter
mine to be congenital anomalies In no event will the term congenital anomaly include condi
tions relating to teeth or intra oral structures supporting the teeth
Cosmetic Any operative procedure or any portion of a procedure performed primarily to improve physical surgery appearance and or treat a mental condition through change in bodily form
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Alliance Health Benefit Plan 2000
Section 9 Fee For Service Facts continued
Custodial care Treatment or services regardless of who recommends them or where they are provided that could be rendered safely and reasonably by a person not medically skilled or that are designed mainly to
help the patient with daily living activities These activities include but are not limited to
1 personal care such as help in walking getting in and out of bed bathing eating by spoon tube
or gastrostomy exercising dressing
2 homemaking such as preparing meals or special diets
3 moving the patient
4 acting as companion or sitter
5 supervising medication that can usually be self administered or
6 treatment or services that any person may be able to perform with minimal instruction includ
ing but not limited to recording temperature pulse and respirations or administration and mon
itoring of feeding systems
The Carrier determines which services are custodial care
Durable medical equipment Equipment and supplies that
1 are prescribed by your attending doctor
2 are medically necessary
3 are primarily and customarily used only for a medical purpose
4 are generally useful only to a person with an illness or injury
5 are designed for prolonged use and
6 serve a specific therapeutic purpose in the treatment of an illness or injury
Effective date The date the benefits described in this brochure are effective
Benefits described in this brochure are effective January 1 for continuing enrollments For new
enrollees in this Plan the effective date of enrollment is determined by the employing office or
retirement system of the enrollee
Experimental or See page 10 investigational
Group health Health care coverage that a member is eligible for because of employment by membership in or coverage connection with a particular organization or group that provides payment for hospital medical or
other health care services or supplies or that pays a specific amount for each day or period of hos
pitalization if the specified amount exceeds 200 per day including extension of any of these ben
efits through COBRA
Home health care A plan of continued care and treatment of an injured or sick person who is under the care of a doc tor and whose doctor certifies that without the home health care confinement in a hospital or
skilled nursing facility would be required
Home health care A public agency or private organization that is licensed as a Home Health Care Agency by the state agency and is certified as such under Medicare
Hospice care Professional inpatient and outpatient care rendered by a licensed or certified hospice to terminally program ill patients for personal care and relief of pain using technical and related medical procedures
Initial emergency Initial emergency treatment is care rendered by a hospital or doctor for an accidental injury Initial treatment emergency treatment does not include benefits for ambulance transportation or treatment an
enrollee receives as a result of an inpatient admission Once the enrollee is admitted to the hospi
tal inpatient benefits will be applied
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Alliance Health Benefit Plan 2000
Section 9 Fee for Service facts continued
Medical The sudden and unexpected onset of a condition or an injury that you believe endangers your life or emergency could result in serious injury or disability and requires immediate medical or surgical care Medical
emergencies include heart attacks poisonings loss of consciousness or respiration convulsions and
such other acute conditions
Medically Services drugs supplies or equipment provided by a hospital or covered provider of the health care necessary services that the Carrier determines
1 are appropriate to diagnose or treat the patient s condition illness or injury
2 are consistent with standards of good medical practice in the United States
3 are not primarily for the personal comfort or convenience of the patient the family or the
provider
4 are not a part of or associated with the scholastic education or vocational training of the patient
and
5 in the case of inpatient care cannot be provided safely on an outpatient basis
The fact that a covered provider has prescribed recommended or approved a service supply drug
or equipment does not in itself make it medically necessary
Mental conditions Conditions and diseases listed in the most recent edition of the International Classification of substance abuse Diseases ICD as psychoses neurotic disorders or personality disorders other nonpsychotic mental
disorders listed in the ICD to be determined by the Carrier or disorders listed in the ICD requiring
treatment for abuse of or dependence upon substances such as alcohol narcotics or hallucinogens
Reasonable and The Plan allows benefits unless otherwise indicated to the extent that they are reasonable and cus customary tomary The reasonable and customary charge for any non PPO service or supply is the charge deter
mined by the Plan on a semiannual basis to be in the 90th percentile of the prevailing charges made
for a service or supply by providers in the geographic area where it is furnished The prevailing
charges data is obtained from prevailing health care charge guides such as that prepared by the Health
Insurance Association of America HIAA and the Plan s administrator First Health In determining
the reasonable charge for a service or supply that is unusual or not often provided in the area or pro
vided by only a small number of providers in the area the Plan may take into account factors such as
the complexity the degree of skills needed the type of specialty of the provider the range of services
or supplies provided by a facility and the prevailing charge in other areas When a PPO provider is
used the fee that has been negotiated between the Plan and the PPO provider is considered the rea
sonable and customary charge
Sound natural A tooth that is whole or properly restored and is without impairment periodontal or other condi teeth tions and is not in need of treatment provided for any reason other than an accidental injury
Section 10 FEHB Facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right the following to information about your health plan its networks providers and facilities You can also find out
information about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM s website
www opm gov lists specific types of information that we must make available to you
If you want specific information about us call 1 800 321 0347 or write to Alliance Health Benefit
Plan 1628 Eleventh Street NW Washington D C 20001 You may also contact us by fax at 202 939
6389 or visit our website at www ahbp com
Where do I get information Your employing or retirement office can answer your questions and give you a Guide to Federal about enrolling in the Employees Health Benefits Plans brochures for other plans and other materials you need to make
FEHB Program an informed decision about
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter mil
itary service or retire
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Alliance Health Benefit Plan 2000
Section 10 FEHB Facts continued
When your enrollment ends and
The next Open Season for enrollment
We don t determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and premiums effective and premiums begin on the first day of your first pay period that starts on or after January 1
Annuitants premiums begin January 1
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been I retire enrolled in the FEHB Program for the last five years of your federal service If you do not meet this
requirement you may be eligible for other forms of coverage such as Temporary Continuation of
Coverage which is described later in this section
What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your are available for me unmarried children under age 22 including any foster or step children your employing or retire
and my family ment office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who became incapable of self support before 22
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry
give birth or add a child to your family You may change your enrollment 31 days before to 60 days
after you give birth or add the child to your family The benefits and premiums for your Self and
Family enrollment begin on the first day of the pay period in which the child is born or becomes
an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligi
ble to receive health benefits nor will we Please tell us immediately when you add or remove fam
ily members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not enroll in
another FEHB plan
Are my medical records We will keep your medical and claims information confidential Only the following will have and claims records access to it
confidential OPM this Plan and our subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of
Workers Compensation Programs OWCP when coordinating benefit payments and subro
gating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal
actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your
identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form cards SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use
an Employee Express confirmation letter
What if I paid a deductible Your old plan s deductible continues until our coverage begins under my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before conditions you enrolled in this Plan solely because you had the condition before you enrolled
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Alliance Health Benefit Plan 2000
Section 10 FEHB Facts continued
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this plan
Your enrollment ends unless you cancel your enrollment or ends
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits coverage under your spouse s enrollment But you may be eligible for your own FEHB coverage under the
spouse equity law If you are recently divorced or are anticipating a divorce contact your former
spouse s employing or retirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you
can receive TCC if you are not able to continue your FEHB enrollment after you retire You may
not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about You can pick a new plan TCC
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums
from the 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government
does not share your cost
You receive another 31 day extension of coverage when your TCC enrollment ends unless you
cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no
longer an eligible family member That office will send you information about enrolling in TCC
You must enroll your child within 60 days after they become eligible for TCC or receive this notice
whichever is later
Former spouses You or your former spouse must notify your employing or retirement office with
in 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling
in TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify
your employing or retirement office within the 60 day deadline
How can I convert You may convert to an individual policy if to individual coverage
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did
not pay your premium you cannot convert
You decided not to receive overage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
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Alliance Health Benefit Plan 2000
Section 10 FEHB Facts continued
If you leave Federal service your employing office will notify you if individual coverage is avail
able You must apply in writing to us within 31 days after you receive this notice However if you
are a family member who is losing coverage the employing or retirement office will not notify you
You must apply in writing to us within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have
to answer questions about your health and we will not impose a waiting period or limit your cov
erage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan Coverage insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions
for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well
Department of Defense FEHB Demonstration Project
What is the Department of The National Defense Authorization Act for 1999 Public Law 105 261 established the Defense DoD and FEHB DoD FEHBP Demonstration Project It allows some active and retired uniformed service members
Program Demonstration and their dependents to enroll in the FEHB Program The demonstration will last for three years Project beginning with the 1999 Open Season for the year 2000 Open Season enrollments will be effective
January 1 2000 DoD and OPM have set up some special procedures to successfully implement the
Demonstration Project noted below Otherwise the provisions described in this brochure apply
Who is Eligible DoD determines who is eligible to enroll in the FEHB Generally you may enroll if
You are an active or retired uniformed service member and are eligible for Medicare
You are a dependent of an active or retired uniformed service member and are eligible for
Medicare
You are a qualified former spouse of an active or retired uniformed service member and you
have not remarried or
You are a survivor dependent of a deceased active or retired uniformed service member and
You live in one of the eight geographic demonstration areas
If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits Program
you are not eligible to enroll under the DoD FEHBP Demonstration Project
Where are the Dover AFB DE demonstration areas
Commonwealth of Puerto Rico
Fort Knox KY
Greensboro Winston Salem High Point NC
Dallas TX
Humboldt County CA area
Naval Hospital Camp Pendleton CA
New Orleans LA
When can I join Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through December 13 1999 Your coverage will begin January 1 2000 DoD has set up an Information Pro
cessing Center IPC in Iowa to provide you with information about how to enroll IPC staff will verify
your eligibility and provide you with FEHB Program information plan brochures enrollment instruc
tions and forms The toll free phone number for the IPC is 1 877 DOD FEHB 1 877 363 3342
You may select coverage for yourself self only or for you and your family self and family dur
ing the 1999 2000 and 2001 Open Seasons Your coverage will begin January 1 of the year fol
lowing the Open Season that you enrolled
If you become eligible for the DoD FEHBP Demonstration Project outside of Open Season con
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Alliance Health Benefit Plan 2000
Department of Defense FEHB Demonstration Project continued
tact the IPC to find out how to enroll and when your coverage will begin
DoD has a web site devoted to the Demonstration Project You can view information such as their
Marketing Beneficiary Education Plan Frequently Asked Questions demonstration area locations
and zip code lists at www tricare osd mil fehbp You can also view information about the demon
stration project including The 2000 Guide to Federal Employees Health Benefits Plans
Participating in the DoD FEHBP Demonstration Project on the OPM web site at www opm gov
Am I eligible for See Section 10 FEHB Facts for information about TCC Under this Demonstration Project the Temporary Continuation only individual eligible for TCC is one who ceases to be eligible as a member of family under
of Coverage TCC your self and family enrollment This occurs when a child turns 22 for example or if you divorce and your spouse does not qualify to enroll as an unremarried former spouse under title 10 United
States Code For these individuals TCC begins the day after their enrollment in the DoD FEHBP
Demonstration Project ends TCC enrollment terminates after 36 months or the end of the
Demonstration project whichever occurs first You your child or another person must notify the
IPC when a family member loses eligibility for coverage under the DoD FEHBP Demonstration
Project
TCC is not available if you move out of a DoD FEHBP Demonstration Project area you cancel
your coverage or your coverage is terminated for any reason TCC is not available when the
demonstration project ends
Do I have the 31 Day These provisions do not apply to the DoD FEHBP Demonstration Project Extension and Right
To Convert
Inspector General Advisory Stop Health Care Fraud Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services
you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 800 321 0347 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415
enalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may investi
gate anyone who uses an ID card if they
Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you
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Alliance Health Benefit Plan 2000
Summary of Benefits for Alliance Health Benefit Plan 2000 Do not rely on this chart alone All benefits are subject to the definitions limitations and exclusions set forth in the brochure This
chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure All items below
with an are subject to the 100 PPO calendar year deductible Those items designated with a are subject to the 300 Non PPO calendar year deductible
Benefits Plan pays provides age
Inpatient Hospital PPO benefit After 150 deductible per admission care 90 Room and board and other hospital charges
Non PPO benefit After 250 deductible per admission 70 Room and board and other hospital charges 12 13
Surgical PPO benefit 90 of PPO contracted rate Non PPO benefit 70 of reasonable and customary charges 14 18
Medical PPO benefit 90 of PPO contracted rate Non PPO benefit 70 of reasonable and customary charges 21 23
Maternity Same benefit as for illness or injury 18 19
Mental Conditions After you pay the 500 deductible for covered hospital charges per person per confinement the Plan will pay 80 of the PPO contracted rate for a PPO facility
or 80 of reasonable and customary charges of a non PPO facility for treatment of mental conditions up to 45 days per person per calendar year 20
Substance Abuse 100 of charges up to 4,000 maximum benefit per calendar year in an approved JCAHO facility limited to a lifetime maximum of 60 inpatient days per person 20
Outpatient Hospital PPO benefit 90 of the PPO contracted rate Care Non PPO benefit 70 of reasonable and customary charges 14
Surgical PPO benefit 90 of the PPO contracted rate Non PPO benefit 70 of reasonable and customary charges 14 18
Medical PPO benefit 90 of covered medical expenses office visits 10 per visit copay Non PPO benefit 70 of covered medical expenses 21 23
Maternity Same benefits as for illness or injury 18 19
Home Health Care Up to 40 per visit for up to 60 home health care visits in a calendar year 24
Mental Conditions 50 or 50 of covered charges up to 45 visits outpatient and inpatient combined per person each calendar year 20
Substance Abuse 75 or 75 of covered charges up to a 4,000 maximum per person each calendar year 21
Emergency care 100 of reasonable and customary charges for emergency treatment accidental injury other than surgery by a doctor and outpatient services furnished by a
hospital when provided within 72 hours after an accidental injury 24
Prescription Retail drug After combined 200 annual drug deductible member pays a 10 copay for the initial drugs program prescription and two refills 50 of charges for the third and subsequent refills
dispensed up to a 30 day supply per prescription or refill 26 27
Mail order After combined 200 annual drug deductible member pays 20 coinsurance per generic prescription and per brand name prescription Member may receive a new 45
day supply and subsequent refills of up to a 90 day supply 26 27
Dental care Dental Benefits The plan offers a dental PPO benefit which has no annual deductible for in network and out of network deductible of 25 per individual and 50 per family
The annual benefit maximum for combined in network and out network is 500 Listed In network services covered at 100 and out of network services covered at 90 28
Additional benefits Chiropractic services Home health care Hospice care Nursing services Well child care and Skilled nursing facilities 23
Protection against Plan pays 100 of reasonable and customary charges if your out of pocket expenses catastrophic costs exceed 2,000 under PPO 3,000 under non PPO for Self Only or for Self and Family
in a calendar year 37 38
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Alliance Health Benefit Plan
2000 1 800 321 0347
Notes
Authorized for distribution by the
United States
Office of
Personnel AH HB BP P
Management A RI 71 003
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48
Alliance Health Benefit Plan
2000 1 800 321 0347
Notes
Authorized for distribution by the
United States
Office of
Personnel AH HB BP P
Management A RI 71 003
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Alliance Health Benefit Plan 2000
Authorized for distribution by the
United States Office of
ersonnel Management
2000 Rate Information for
Alliance Health Benefit Plan
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment
ostal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as Category A rates and Category B rates will apply for certain career employees If you are a
career postal employee but not a member of a special postal employment class refer to the category defini tions in The Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees
RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members of any postal employee organization Such persons not subject to postal rates
must refer to the applicable Guide to Federal Employees Health Benefits Plans
Non Postal Premium ostal Premium A ostal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov t Your Gov t Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Self Only 1R1 78.83 55.59 170.80 120.44 93.06 41.36 93.26 41.16
Self and Family 1R2 175.97 109.00 381.27 236.17 207.74 77.23 201.02 83.95
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